Provider Demographics
NPI:1427195189
Name:LOGAN, MAIYA (OD)
Entity Type:Individual
Prefix:DR
First Name:MAIYA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MAIYA
Other - Middle Name:LOGAN
Other - Last Name:LEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:24228 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6505
Mailing Address - Country:US
Mailing Address - Phone:310-378-8297
Mailing Address - Fax:310-378-1527
Practice Address - Street 1:24228 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6505
Practice Address - Country:US
Practice Address - Phone:310-378-8297
Practice Address - Fax:310-378-1527
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10365T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103650Medicaid
CAOP10365Medicare ID - Type Unspecified
CASD0103650Medicaid