Provider Demographics
NPI:1952146987
Name:MATHUS, LOGAN DISHAWN (PTT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:DISHAWN
Last Name:MATHUS
Suffix:
Gender:M
Credentials:PTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 ENGLISH AVE UNIT G2
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-2177
Mailing Address - Country:US
Mailing Address - Phone:754-235-1328
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-7081
Practice Address - Country:US
Practice Address - Phone:301-677-8796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider