Provider Demographics
NPI:1851146229
Name:SOUTHWELL, LOGAN MCHAEL
Entity Type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:MCHAEL
Last Name:SOUTHWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9002
Mailing Address - Country:US
Mailing Address - Phone:405-878-3854
Mailing Address - Fax:405-273-1752
Practice Address - Street 1:1601 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9002
Practice Address - Country:US
Practice Address - Phone:405-878-3854
Practice Address - Fax:405-273-1752
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist