Provider Demographics
NPI:1467907063
Name:OLIVER, LOGAN (OD)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:OLIVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 GRAYSON ST
Mailing Address - Street 2:PO BOX 1119
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-6006
Mailing Address - Country:US
Mailing Address - Phone:336-372-4493
Mailing Address - Fax:336-372-2035
Practice Address - Street 1:18 GRAYSON ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-6006
Practice Address - Country:US
Practice Address - Phone:336-372-4493
Practice Address - Fax:336-372-2035
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist