Provider Demographics
NPI:1821060492
Name:LOGAN, LORETTA MICHELLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:MICHELLE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 HUNTER AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1543
Mailing Address - Country:US
Mailing Address - Phone:718-676-5262
Mailing Address - Fax:
Practice Address - Street 1:241 W 138TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2102
Practice Address - Country:US
Practice Address - Phone:212-694-2392
Practice Address - Fax:212-694-4020
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO4658213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY480026772OtherRAILROAD MEDICARE
NY01148892Medicaid
NY01148892Medicaid
NYT89850Medicare UPIN
NYP50481Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
NY6071980001Medicare NSC