Provider Demographics
NPI:1891832747
Name:LOGAN, WILLIAM D JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:D
Last Name:LOGAN
Suffix:JR
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 1:310 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-3809
Mailing Address - Country:US
Mailing Address - Phone:601-267-1100
Mailing Address - Fax:601-267-1191
Practice Address - Street 1:310 ELLIS ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-3809
Practice Address - Country:US
Practice Address - Phone:601-267-1100
Practice Address - Fax:601-267-1191
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03214207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0011960Medicaid
MS03214OtherMS MEDICAL LICENSE
MS03214OtherMS MEDICAL LICENSE