Provider Demographics
NPI:1962407825
Name:LOGAN, KENNETH D (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:236 W EAST AVE
Mailing Address - Street 2:PMB 252
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-7235
Mailing Address - Country:US
Mailing Address - Phone:530-571-2034
Mailing Address - Fax:530-896-4893
Practice Address - Street 1:15151 LITTLE RON RD
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-9455
Practice Address - Country:US
Practice Address - Phone:530-571-2034
Practice Address - Fax:530-896-4893
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G508000Medicaid
CAPENDINGMedicare PIN
CAA51810Medicare UPIN