Provider Demographics
NPI:1801059381
Name:LOGAN, JOHN RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RYAN
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1812 SHELBY LN
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5055
Mailing Address - Country:US
Mailing Address - Phone:601-624-8229
Mailing Address - Fax:
Practice Address - Street 1:2101 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5340
Practice Address - Country:US
Practice Address - Phone:228-809-5510
Practice Address - Fax:228-809-5519
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-06
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS21375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS21375OtherMS STATE BOARD OF MEDICAL LICENSURE
MS21375OtherMS LICENSE