Provider Demographics
NPI:1336213552
Name:LOGAN, WILLIAM J (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:LOGAN
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 1:12012 VEIRS MILL RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-4513
Mailing Address - Country:US
Mailing Address - Phone:301-370-0810
Mailing Address - Fax:240-342-2801
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-546-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0022025207ZP0102X
DEC1-0005172207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD338221402Medicaid
DC414886YFA6Medicare PIN