Provider Demographics
NPI:1477584001
Name:LOGAN, JAMES RUSSELL (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RUSSELL
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6470 PENTZ RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969
Mailing Address - Country:US
Mailing Address - Phone:530-872-6655
Mailing Address - Fax:530-872-6653
Practice Address - Street 1:6470 PENTZ RD
Practice Address - Street 2:SUITE A
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969
Practice Address - Country:US
Practice Address - Phone:530-872-6655
Practice Address - Fax:530-872-6653
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG72586208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01920ZOtherBLUE SHIELD
CAF72113Medicare UPIN