Provider Demographics
NPI:1720077407
Name:LOGAN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:1401 PROFESSIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-8014
Mailing Address - Country:US
Mailing Address - Phone:812-473-2060
Mailing Address - Fax:812-473-0763
Practice Address - Street 1:1401 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-8014
Practice Address - Country:US
Practice Address - Phone:812-473-2060
Practice Address - Fax:812-473-0763
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32870207Y00000X
IN01046534A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN064945OtherHEALTH ALLIANCE
IN394258OtherHEALTHLINK
KY64328701Medicaid
KY040003023OtherRR MEDICARE
INP00076697OtherRR MEDICARE
KY000000045660OtherANTHEM
IN000000045660OtherANTHEM
IN200149220AMedicaid