Provider Demographics
NPI:1326081761
Name:LOGAN, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
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 1:8255 MANASOTA KEY RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-9328
Mailing Address - Country:US
Mailing Address - Phone:941-475-2250
Mailing Address - Fax:
Practice Address - Street 1:1885 ENGLEWOOD RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-1822
Practice Address - Country:US
Practice Address - Phone:941-475-8291
Practice Address - Fax:941-473-3609
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08102WMedicare PIN
FLD51982Medicare UPIN