Provider Demographics
NPI:1568428498
Name:LOGAN, THEODORE F (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:F
Last Name:LOGAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 BARNHILL DR
Practice Address - Street 2:RT 473
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5112
Practice Address - Country:US
Practice Address - Phone:317-278-7576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051224A207R00000X, 207RX0202X, 207RH0003X
IN01051224207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000109649OtherANTHEM PTAN
IN200243290Medicaid
IN264910DNMedicare PIN