Provider Demographics
NPI:1992704290
Name:LOGAN, PATRICK CLIFFORD (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:CLIFFORD
Last Name:LOGAN
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 1:1910 N ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46218-5199
Mailing Address - Country:US
Mailing Address - Phone:317-359-5358
Mailing Address - Fax:317-359-5358
Practice Address - Street 1:1910 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-5128
Practice Address - Country:US
Practice Address - Phone:317-359-5358
Practice Address - Fax:317-359-5358
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020481A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100055560AMedicaid
IN072068448OtherRAILROAD MEDICARE
IN072068448OtherRAILROAD MEDICARE
D67805Medicare UPIN
IN100055560AMedicaid
INP060280AMedicare Oscar/Certification