Basic Information
| Provider Information | |||||||||
| NPI: | 1396276135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDRENEAU | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | RODNEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843966 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738843300 | ||||||||
| FaxNumber: | 5738840943 | ||||||||
| Practice Location | |||||||||
| Address1: | 3215 WINGATE CT STE 102 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652017689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738843937 | ||||||||
| FaxNumber: | 5738844868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2017 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 2022019738 | MO | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 85613 | SC | N | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207WX0120X | 2022019738 | MO | Y |
ID Information
| ID | Type | State | Issuer | Description | 200064204 | 05 | MO | MEDICAID |