Provider Demographics
NPI:1053383729
Name:LOGAN, JEREMY JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JAMES
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 1:1460 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6061
Mailing Address - Country:US
Mailing Address - Phone:541-382-6633
Mailing Address - Fax:541-383-4577
Practice Address - Street 1:1460 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6061
Practice Address - Country:US
Practice Address - Phone:541-382-6633
Practice Address - Fax:541-383-4577
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81641-202085R0202X
NMMD2005-05452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM83852Medicaid
AZ992108Medicaid
202003153OtherPRESBYTERIAN HEALH/SALUD
NM83852Medicaid
AZ992108Medicaid
NM286484YRODMedicare PIN