Healthcare Provider Details

I. General information

NPI: 1104387794
Provider Name (Legal Business Name): LOGAN DEBORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

984 N 10 MILE DR #103
FRISCO CO
80443-5719
US

IV. Provider business mailing address

7300 RANCH ROAD 2222, BUILDING 1, STE 200
AUSTIN TX
78730
US

V. Phone/Fax

Practice location:
  • Phone: 970-668-0998
  • Fax:
Mailing address:
  • Phone: 512-628-0465
  • Fax: 512-233-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDR.0069923
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: