Healthcare Provider Details

I. General information

NPI: 1164572186
Provider Name (Legal Business Name): IAN J LOGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2068 JOHN JONES ROAD SUITE # 3116
DAVIS CA
95616-9711
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 530-747-0389
  • Fax: 530-747-0623
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA97807
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: