Provider Demographics
NPI:1912352675
Name:BOLDWILL, LOGAN WIGGINS (MD)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:WIGGINS
Last Name:BOLDWILL
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 1:510B KAREY DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-8727
Mailing Address - Country:US
Mailing Address - Phone:903-539-6544
Mailing Address - Fax:
Practice Address - Street 1:2000 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-5610
Practice Address - Country:US
Practice Address - Phone:903-676-1000
Practice Address - Fax:903-676-1337
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9574207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine