Provider Demographics
NPI:1558517144
Name:LOGAN, LATANIA K (MD, MSPH)
Entity Type:Individual
Prefix:DR
First Name:LATANIA
Middle Name:K
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD, MSPH
Other - Prefix:DR
Other - First Name:LATANIA
Other - Middle Name:K
Other - Last Name:BROYLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:STE 710
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-6396
Mailing Address - Fax:312-942-4168
Practice Address - Street 1:1400 TULLIE RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2309
Practice Address - Country:US
Practice Address - Phone:404-785-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113313208000000X, 2080P0208X
GA920992080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-113313OtherSTATE LICENSE NUMBER
IL336-074676OtherSTATE LICENSE, CONTROLLED SUBSTANCE
GA92099OtherSTATE LICENSE NUMBER