Provider Demographics
NPI:1689364507
Name:WEITHMAN, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:WEITHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 RYAN MEADOW PL
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:OH
Mailing Address - Zip Code:43021-9205
Mailing Address - Country:US
Mailing Address - Phone:614-507-0429
Mailing Address - Fax:
Practice Address - Street 1:3773 OLENTANGY RIVER RD STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3425
Practice Address - Country:US
Practice Address - Phone:614-407-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT020425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist