Healthcare Provider Details

I. General information

NPI: 1710731591
Provider Name (Legal Business Name): LOGAN RUBIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST STE 1017
DETROIT MI
48201-2017
US

IV. Provider business mailing address

5570 PEDRICK PLANTATION CIR
TALLAHASSEE FL
32317-8203
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4123
  • Fax:
Mailing address:
  • Phone: 505-974-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: