Provider Demographics
NPI:1760173017
Name:GORDON, LOGAN DANIEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:DANIEL
Last Name:GORDON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 HOWARD ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-4003
Mailing Address - Country:US
Mailing Address - Phone:478-283-8094
Mailing Address - Fax:
Practice Address - Street 1:488 N MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2386
Practice Address - Country:US
Practice Address - Phone:770-619-5801
Practice Address - Fax:770-619-5806
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016539208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation