Healthcare Provider Details

I. General information

NPI: 1235623281
Provider Name (Legal Business Name): AMY BROOKE LOGAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 UNIVERSITY BLVD G080A
BIRMINGHAM AL
35294-0010
US

IV. Provider business mailing address

3346 WESTMORELAND DR
ROANOKE VA
24018-3635
US

V. Phone/Fax

Practice location:
  • Phone: 205-975-2020
  • Fax: 205-934-6755
Mailing address:
  • Phone: 256-310-2032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002666
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-E10-TA-B46
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: