Provider Demographics
NPI:1669685301
Name:LOGUE, MARK P (CPO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:P
Last Name:LOGUE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2214 DONATO DR
Mailing Address - Street 2:
Mailing Address - City:BELLEAIR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33786-3433
Mailing Address - Country:US
Mailing Address - Phone:727-449-9292
Mailing Address - Fax:727-449-9393
Practice Address - Street 1:516 LAKEVIEW RD
Practice Address - Street 2:VILLA 1
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3302
Practice Address - Country:US
Practice Address - Phone:727-449-9292
Practice Address - Fax:727-449-9393
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00178OtherQUALITY HEALTH CARE
FLM0692OtherBLUE CROSS BLUE SHIELD
FL00124OtherUNIVERSAL HEALTHCARE
FL5045990001Medicare NSC