Provider Demographics
NPI:1043230089
Name:LOGSDON, PHILLIP K (DPM)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:K
Last Name:LOGSDON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1802 S. MATTIS AVENUE
Practice Address - Street 2:ORTHOPEDICS
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821
Practice Address - Country:US
Practice Address - Phone:217-383-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003166213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL480014262OtherRAILROAD
T37466Medicare UPIN
IL480014262OtherRAILROAD
IL6447860013Medicare NSC
ILIL3270334Medicare PIN
ILT37466Medicare UPIN