Healthcare Provider Details

I. General information

NPI: 1538135868
Provider Name (Legal Business Name): JOHN BRISBANE LOGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29301 N DIXIE RANCH RD
LACOMBE LA
70445
US

IV. Provider business mailing address

29301 N DIXIE RANCH RD
LACOMBE LA
70445
US

V. Phone/Fax

Practice location:
  • Phone: 985-871-4114
  • Fax: 985-871-4130
Mailing address:
  • Phone: 985-871-4114
  • Fax: 985-871-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number020254
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: