Healthcare Provider Details

I. General information

NPI: 1750760187
Provider Name (Legal Business Name): LOGAN CRAIG WALTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 E BASELINE RD STE 129
MESA AZ
85206-4679
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 480-644-1001
  • Fax: 480-464-8722
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number8486
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberIN PROGRESS
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: