Healthcare Provider Details

I. General information

NPI: 1801733506
Provider Name (Legal Business Name): LOGAN BURTENSHAW DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

V. Phone/Fax

Practice location:
  • Phone: 313-593-7000
  • Fax:
Mailing address:
  • Phone: 313-593-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5151018096
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: