Provider Demographics
NPI:1750311395
Name:LOGAN, WILLIAM R (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:STE 5003-B
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-227-2020
Mailing Address - Fax:314-227-2021
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:STE 5003-B
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-227-2020
Practice Address - Fax:314-227-2021
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2009-12-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR1A502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202000006LOMedicaid
MO202000006LOMedicaid
000001769Medicare ID - Type Unspecified