Provider Demographics
NPI:1982716221
Name:LOGAN, SUSAN C (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1111 SONOMA AVENUE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-575-1626
Mailing Address - Fax:707-575-3941
Practice Address - Street 1:1111 SONOMA AVENUE
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-575-1626
Practice Address - Fax:707-575-3941
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG69486207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01350003OtherRAILROAD MEDICARE
CA1982716221Medicaid
CACA122501Medicare PIN