Provider Demographics
NPI:1952565491
Name:HAAK, LOGAN MILAD (MD)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:MILAD
Last Name:HAAK
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 1:6259 CAMINITO LUISITO
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7214
Mailing Address - Country:US
Mailing Address - Phone:858-863-7597
Mailing Address - Fax:
Practice Address - Street 1:1855 1ST AVE
Practice Address - Street 2:STE 200B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2685
Practice Address - Country:US
Practice Address - Phone:858-863-7597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49767207WX0107X, 207W00000X
CA110896207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ977504Medicaid
AZ977504Medicaid
IL532050001Medicare PIN
INM400074572Medicare PIN
IL669900004Medicare PIN