MEDICARE: DR. LORETTA MICHELLE LOGAN DPM

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	213EP1101X	Primary Podiatric Medicine Podiatrist	NOO4658	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	480026772	OTHER	NY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821060492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORETTA MICHELLE LOGAN DPM

Provider Business Mailing Address
First Line	:	3307 HUNTER AVE
Second Line	:	APT 1
City	:	BRONX
State	:	NY
Zip	:	10475-1543
Country	:	US
Telephone Number	:	718-676-5262
Fax Number	:

Provider Business Practice Location Address
First Line	:	241 W 138TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10030-2102
Country	:	US
Telephone Number	:	212-694-2392
Fax Number	:	212-694-4020

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

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	12/02/2009

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