Provider Demographics
NPI:1699078865
Name:LOGAN, CARY PHILLIP (MD)
Entity type:Individual
Prefix:MR
First Name:CARY
Middle Name:PHILLIP
Last Name:LOGAN
Suffix:
Gender:M
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:PO BOX 15204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5204
Mailing Address - Country:US
Mailing Address - Phone:702-677-2644
Mailing Address - Fax:702-796-0856
Practice Address - Street 1:350 E DESERT INN RD UNIT G103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-9007
Practice Address - Country:US
Practice Address - Phone:702-677-2644
Practice Address - Fax:702-796-0856
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7068207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine