Healthcare Provider Details

I. General information

NPI: 1952146987
Provider Name (Legal Business Name): LOGAN DISHAWN MATHUS PTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 LLEWELLYN AVE
FORT MEADE MD
20755-7081
US

IV. Provider business mailing address

4755 ENGLISH AVE UNIT G2
FORT GEORGE G MEADE MD
20755-2177
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-8796
  • Fax:
Mailing address:
  • Phone: 754-235-1328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: