Provider Demographics
NPI:1225073422
Name:CHARLES-LOGAN, CONSTANCE M (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:M
Last Name:CHARLES-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 1:2211 60TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5569
Mailing Address - Country:US
Mailing Address - Phone:941-761-0663
Mailing Address - Fax:941-761-3347
Practice Address - Street 1:1414 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4607
Practice Address - Country:US
Practice Address - Phone:941-761-0663
Practice Address - Fax:941-761-3347
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61745174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF60745Medicare UPIN