Provider Demographics
NPI:1780782953
Name:LOGANATHAN, VIDYA (MD)
Entity type:Individual
Prefix:MRS
First Name:VIDYA
Middle Name:
Last Name:LOGANATHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2457 E MAIN ST STE 1E
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-2684
Mailing Address - Country:US
Mailing Address - Phone:203-753-8477
Mailing Address - Fax:
Practice Address - Street 1:2457 E MAIN ST STE 1E
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2684
Practice Address - Country:US
Practice Address - Phone:203-753-8477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF89153Medicare UPIN