Provider Demographics
NPI:1528036324
Name:LOGAN, ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:FASSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1602 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1192
Mailing Address - Country:US
Mailing Address - Phone:660-885-8171
Mailing Address - Fax:660-890-8487
Practice Address - Street 1:1602 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:660-885-8171
Practice Address - Fax:660-890-8487
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N38207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7879392Medicare ID - Type Unspecified
MOE83490Medicare UPIN