Provider Demographics
NPI:1306663182
Name:WILLEFORD, LOGAN DAVID (SOIDC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:DAVID
Last Name:WILLEFORD
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20184
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-440-2494
Mailing Address - Fax:
Practice Address - Street 1:PSC BOX 20184
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-440-2494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman