Provider Demographics
NPI:1205820008
Name:LOGAN, ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3001
Mailing Address - Country:US
Mailing Address - Phone:585-922-5067
Mailing Address - Fax:585-922-2908
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-5067
Practice Address - Fax:585-922-2908
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251865208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03007063/NWKMedicaid
WI31696100Medicaid
NYJ400078575Medicare PIN
NY70005A/RGHMedicare PIN
E82929Medicare UPIN