Healthcare Provider Details

I. General information

NPI: 1740506419
Provider Name (Legal Business Name): LOGAN B LACKEY II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 S FREMONT AVE SUITE 120
SPRINGFIELD MO
65804-2206
US

IV. Provider business mailing address

2055 S FREMONT AVE SUITE 120
SPRINGFIELD MO
65804-2206
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-2500
  • Fax:
Mailing address:
  • Phone: 417-820-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2016020760
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: