Provider Demographics
NPI:1366121626
Name:MARTIN, LOGAN P (IDMT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:P
Last Name:MARTIN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 103 BOX 4354
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09603-0044
Mailing Address - Country:US
Mailing Address - Phone:413-377-0150
Mailing Address - Fax:
Practice Address - Street 1:UNIT 6180
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604
Practice Address - Country:US
Practice Address - Phone:314-632-1775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians