Provider Demographics
NPI:1538656202
Name:LOGAN, STEWART REESE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEWART
Middle Name:REESE
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 PARK PLZ APT 517
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6742
Mailing Address - Country:US
Mailing Address - Phone:601-826-6669
Mailing Address - Fax:
Practice Address - Street 1:5575 RUFFIN RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1361
Practice Address - Country:US
Practice Address - Phone:858-277-2744
Practice Address - Fax:858-277-3085
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2023-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA167320208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice