Provider Demographics
NPI:1477572881
Name:ELANGOVAN, LOGANATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LOGANATHAN
Middle Name:
Last Name:ELANGOVAN
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 1:1260 SENTRY DR STE 140
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-5990
Mailing Address - Country:US
Mailing Address - Phone:262-524-1024
Mailing Address - Fax:262-524-8767
Practice Address - Street 1:1260 SENTRY DR STE 140
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-5990
Practice Address - Country:US
Practice Address - Phone:262-524-1024
Practice Address - Fax:262-524-8767
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40898-020207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32616600Medicaid
WI0003-30020Medicare PIN
WI0006-68705Medicare PIN
WI32616600Medicaid