Provider Demographics
NPI:1831401967
Name:MITCHELL, LOGAN THOMPSON (OD)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:THOMPSON
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 9TH DR
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1525
Mailing Address - Country:US
Mailing Address - Phone:503-314-3561
Mailing Address - Fax:
Practice Address - Street 1:2150 3RD ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-2609
Practice Address - Country:US
Practice Address - Phone:541-523-5858
Practice Address - Fax:541-523-7652
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3375ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist