Provider Demographics
NPI:1609215573
Name:FREDERICKSON, LOGAN CLAY (DO)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:CLAY
Last Name:FREDERICKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:CLAY
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3705 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1456
Mailing Address - Country:US
Mailing Address - Phone:541-519-4250
Mailing Address - Fax:541-239-5259
Practice Address - Street 1:3705 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1456
Practice Address - Country:US
Practice Address - Phone:541-519-4250
Practice Address - Fax:541-239-5259
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO176820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDO176820OtherMEDICAL LICENSE