Provider Demographics
NPI:1861640039
Name:EDMISTON, LOGAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:J
Last Name:EDMISTON
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 1:860 SMITHFIELD DR
Mailing Address - Street 2:1906
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-3152
Mailing Address - Country:US
Mailing Address - Phone:724-944-2112
Mailing Address - Fax:
Practice Address - Street 1:55 ARCH ST
Practice Address - Street 2:G4
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1423
Practice Address - Country:US
Practice Address - Phone:330-375-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program