Healthcare Provider Details

I. General information

NPI: 1164520714
Provider Name (Legal Business Name): DWAYNE KEITH LOGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5991 E SPRING ST
LONG BEACH CA
90808-3752
US

IV. Provider business mailing address

14726 RAMONA AVE STE 203
CHINO CA
91710-5730
US

V. Phone/Fax

Practice location:
  • Phone: 562-938-9945
  • Fax: 562-496-0433
Mailing address:
  • Phone: 626-305-9100
  • Fax: 626-305-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG68583
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberG68583
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License NumberG68583
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberG68583
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: