Provider Demographics
NPI:1154427144
Name:LOGAN, DEIRDRE DENE (MD)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:DENE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6641 S HALM AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-2225
Mailing Address - Country:US
Mailing Address - Phone:310-403-8993
Mailing Address - Fax:
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:323-357-6582
Practice Address - Fax:323-563-3386
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69173207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA691730OtherMEDI-CAL NOL
CAH97585Medicare UPIN