Provider Demographics
NPI:1164520714
Name:LOGAN, DWAYNE KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:KEITH
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:888 S. DISNEYLAND DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-1828
Mailing Address - Country:US
Mailing Address - Phone:714-821-4666
Mailing Address - Fax:714-533-6800
Practice Address - Street 1:5991 E SPRING ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-3752
Practice Address - Country:US
Practice Address - Phone:562-938-9945
Practice Address - Fax:562-496-0433
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-09-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG68583207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG68583OMedicare PIN
CAF92469Medicare UPIN
WG68583DMedicare PIN