Provider Demographics
NPI:1932377280
Name:GRADDY, LOGAN GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:GABRIEL
Last Name:GRADDY
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 1:910 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4142
Mailing Address - Country:US
Mailing Address - Phone:919-416-4191
Mailing Address - Fax:888-805-6175
Practice Address - Street 1:910 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4142
Practice Address - Country:US
Practice Address - Phone:919-416-4191
Practice Address - Fax:888-805-6175
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-000702084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911215Medicaid