Healthcare Provider Details

I. General information

NPI: 1114427234
Provider Name (Legal Business Name): JOHN LOGUE CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 OLD COURT RD STE 105A
PIKESVILLE MD
21208-2800
US

IV. Provider business mailing address

3800 GLEN AVE
BALTIMORE MD
21215-3530
US

V. Phone/Fax

Practice location:
  • Phone: 443-487-4394
  • Fax: 240-482-8839
Mailing address:
  • Phone: 443-487-4394
  • Fax: 240-482-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: