Provider Demographics
NPI:1427054873
Name:LOGAN, THEODORE P (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:P
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2018
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:12 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2739
Practice Address - Country:US
Practice Address - Phone:207-701-4400
Practice Address - Fax:207-701-4487
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012617208000000X
MEMD126172084P0800X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME255750099Medicaid
ME047853OtherANTHEM STAR NUMBER
ME255750099Medicaid
MEE400329760Medicare PIN