Provider Demographics
NPI:1831372242
Name:LOGAN, SUSAN LEE (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:LOGAN
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 1:7780 N FRESNO ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2413
Mailing Address - Country:US
Mailing Address - Phone:559-500-4502
Mailing Address - Fax:559-573-8749
Practice Address - Street 1:7780 N FRESNO ST
Practice Address - Street 2:STE 100
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2413
Practice Address - Country:US
Practice Address - Phone:559-500-4502
Practice Address - Fax:559-573-8749
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA819582086X0206X, 208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A819580OtherMEDI-CAL