Provider Demographics
NPI:1952560211
Name:BOATMAN, LOGAN (MD)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:BOATMAN
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 1:6550 FANNIN ST
Mailing Address - Street 2:SUITE 749
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-441-7465
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST
Practice Address - Street 2:SUITE 749
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2717
Practice Address - Country:US
Practice Address - Phone:713-441-7465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0031304390200000X
TXP67842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8EU503OtherBLUE CROSS BLUE SHIELD
TX346620302Medicaid
TX346620301Medicaid
TX8EU503OtherBLUE CROSS BLUE SHIELD
TX359894ZHXYMedicare PIN