Provider Demographics
NPI:1689965204
Name:MCGHAN, LOGAN JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:JAMES
Last Name:MCGHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13500 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95415-9133
Mailing Address - Country:US
Mailing Address - Phone:707-895-3477
Mailing Address - Fax:
Practice Address - Street 1:1515 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-9700
Practice Address - Country:US
Practice Address - Phone:541-767-5200
Practice Address - Fax:541-767-5200
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-30
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD181244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689965204Medicaid