Provider Demographics
NPI:1104387794
Name:DEBORD, LOGAN (MD)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:DEBORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222, BUILDING 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:984 N 10 MILE DR
Practice Address - Street 2:#103
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5719
Practice Address - Country:US
Practice Address - Phone:970-668-0998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0069923207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program