Provider Demographics
NPI:1538110424
Name:LOGSDON, MARTIN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:THOMAS
Last Name:LOGSDON
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 1:1700 BLUEGRASS AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215
Mailing Address - Country:US
Mailing Address - Phone:502-363-1841
Mailing Address - Fax:502-366-3317
Practice Address - Street 1:1700 BLUEGRASS AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-363-1841
Practice Address - Fax:502-366-3317
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20406207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64204068Medicaid
1069483OtherPASSPORT
000000047754OtherANTHEM
C70746Medicare UPIN
KY1151601Medicare PIN