Provider Demographics
NPI:1295354025
Name:DEHOFF, LOGAN BARRETT (MD)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:BARRETT
Last Name:DEHOFF
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 1:1034 HAW CREEK CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6513
Mailing Address - Country:US
Mailing Address - Phone:678-381-2020
Mailing Address - Fax:678-381-2015
Practice Address - Street 1:201 KIMBERLY WAY STE 200
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8010
Practice Address - Country:US
Practice Address - Phone:678-381-2020
Practice Address - Fax:678-381-2015
Is Sole Proprietor?:No
Enumeration Date:2020-04-12
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA99728207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program