Provider Demographics
NPI:1124020771
Name:LOGAN, JOHN LANDISS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LANDISS
Last Name:LOGAN
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 1:2005 E 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-1109
Mailing Address - Country:US
Mailing Address - Phone:303-321-4212
Mailing Address - Fax:303-388-2459
Practice Address - Street 1:2005 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-1109
Practice Address - Country:US
Practice Address - Phone:303-321-4212
Practice Address - Fax:303-388-2459
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32200208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01322007Medicaid
CO340012614OtherRAILROAD MEDICARE
CO340012614OtherRAILROAD MEDICARE
COCM4328Medicare PIN
A42057Medicare UPIN