Provider Demographics
NPI:1215318696
Name:LOGAN, ISAIAH (MD)
Entity type:Individual
Prefix:
First Name:ISAIAH
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:ATTN: TRACI MITCHELL - ADMN
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:709 BARTON ST
Practice Address - Street 2:
Practice Address - City:HEARNE
Practice Address - State:TX
Practice Address - Zip Code:77859-3009
Practice Address - Country:US
Practice Address - Phone:979-279-3451
Practice Address - Fax:979-595-1704
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2024-09-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXBP10054656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine