Provider Demographics
NPI:1245220144
Name:LOGAN, JASON A (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
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 1:210 JAMES RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1110
Mailing Address - Country:US
Mailing Address - Phone:731-658-5421
Mailing Address - Fax:
Practice Address - Street 1:7600 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6836
Practice Address - Country:US
Practice Address - Phone:731-228-9778
Practice Address - Fax:918-493-7813
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2010-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22922207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200018630AMedicaid
H98940Medicare UPIN
OK244513215Medicare ID - Type Unspecified