Provider Demographics
NPI:1689873465
Name:LOGENDRA, JAZMIN A (OD)
Entity Type:Individual
Prefix:DR
First Name:JAZMIN
Middle Name:A
Last Name:LOGENDRA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LEHIGH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E LEHIGH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1012
Practice Address - Country:US
Practice Address - Phone:215-634-6563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003113152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00871448OtherRAIL ROAD MEDICARE
TXP00871448OtherRAIL ROAD MEDICARE