Provider Demographics
NPI:1114011566
Name:LOGVIN, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:LOGVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1809
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-0809
Mailing Address - Country:US
Mailing Address - Phone:714-560-1580
Mailing Address - Fax:714-560-1585
Practice Address - Street 1:1650 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3400
Practice Address - Country:US
Practice Address - Phone:916-983-7561
Practice Address - Fax:916-984-7392
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA97020207R00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF340ZMedicare PIN