Provider Demographics
NPI:1457516759
Name:ADINA MANUELA LOGAN MD PA
Entity Type:Organization
Organization Name:ADINA MANUELA LOGAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADINA
Authorized Official - Middle Name:MANUELA
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-484-7500
Mailing Address - Street 1:PO BOX 93644
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0115
Mailing Address - Country:US
Mailing Address - Phone:972-484-7500
Mailing Address - Fax:972-241-4496
Practice Address - Street 1:701 TUSCAN
Practice Address - Street 2:SUITE 145
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3834
Practice Address - Country:US
Practice Address - Phone:972-484-7500
Practice Address - Fax:972-241-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030844701Medicaid
G69579Medicare UPIN