Provider Demographics
NPI:1255957817
Name:MICHAEL, LOGAN (OD)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 HORNBECK RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4757
Mailing Address - Country:US
Mailing Address - Phone:304-685-2753
Mailing Address - Fax:
Practice Address - Street 1:187 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1315
Practice Address - Country:US
Practice Address - Phone:740-593-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.006901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOPT.006901OtherLICENSE NUMBER