Provider Demographics
NPI:1679519417
Name:ALONZO J LOGAN MD PA
Entity Type:Organization
Organization Name:ALONZO J LOGAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALONZO
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:407-846-3535
Mailing Address - Street 1:102 PARK PL
Mailing Address - Street 2:STE D-1
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741
Mailing Address - Country:US
Mailing Address - Phone:407-846-3535
Mailing Address - Fax:
Practice Address - Street 1:102 PARK PL
Practice Address - Street 2:STE D-1
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741
Practice Address - Country:US
Practice Address - Phone:407-846-3535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty