MEDICARE: DAKEYA D LOGAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	2014-00339	NC

General Provider Information

NPI Number	:	1700015971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAKEYA D LOGAN MD

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3193 W HIGHWAY 74
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-8437
Country	:	US
Telephone Number	:	704-698-4089
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2009
Last Update Date	:	07/15/2024

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