Provider Demographics
NPI:1922005966
Name:LOGSDON, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LOGSDON
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 1:601 E ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:407-200-2355
Mailing Address - Fax:
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-200-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME615872085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370023200Medicaid
FL300032799OtherRR MEDICARE
FL14887OtherBCBS OF FLORIDA
FLF24613Medicare UPIN
FL14887AMedicare PIN
FL300032799OtherRR MEDICARE