Provider Demographics
NPI:1972037018
Name:VANDER WOUDE, LOGAN TAYLOR (DO, MPH)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:TAYLOR
Last Name:VANDER WOUDE
Suffix:
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4511
Mailing Address - Country:US
Mailing Address - Phone:772-299-1404
Mailing Address - Fax:
Practice Address - Street 1:3500 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4511
Practice Address - Country:US
Practice Address - Phone:772-299-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-15
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17574207Q00000X, 207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS17574OtherMEDICAL LICENSE