Provider Demographics
NPI:1235623281
Name:LOGAN, AMY BROOKE (OD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BROOKE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3346 WESTMORELAND DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3635
Mailing Address - Country:US
Mailing Address - Phone:256-310-2032
Mailing Address - Fax:
Practice Address - Street 1:1716 UNIVERSITY BLVD
Practice Address - Street 2:G080A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294-0010
Practice Address - Country:US
Practice Address - Phone:205-975-2020
Practice Address - Fax:205-934-6755
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002666152W00000X
ALS-E10-TA-B46152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist