Healthcare Provider Details

I. General information

NPI: 1508333758
Provider Name (Legal Business Name): LC LOGGINS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 ALTAMONT AVE
OAKLAND CA
94605-2603
US

IV. Provider business mailing address

4041 ALTAMONT AVE
OAKLAND CA
94605-2603
US

V. Phone/Fax

Practice location:
  • Phone: 510-646-6666
  • Fax:
Mailing address:
  • Phone: 510-646-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberE3506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: