Provider Demographics
NPI:1457022998
Name:LOGAN, MARK EDWARD
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:LOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHINCOTEAGUE
Mailing Address - State:VA
Mailing Address - Zip Code:23336-1857
Mailing Address - Country:US
Mailing Address - Phone:757-336-2844
Mailing Address - Fax:757-336-2811
Practice Address - Street 1:3823 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHINCOTEAGUE
Practice Address - State:VA
Practice Address - Zip Code:23336-1857
Practice Address - Country:US
Practice Address - Phone:757-336-2844
Practice Address - Fax:757-336-2811
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman