Healthcare Provider Details

I. General information

NPI: 1407019375
Provider Name (Legal Business Name): ANDREA F LOGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 OCEAN SPRINGS RD
OCEAN SPRINGS MS
39564-3421
US

IV. Provider business mailing address

1129 OCEAN SPRINGS RD
OCEAN SPRINGS MS
39564-3421
US

V. Phone/Fax

Practice location:
  • Phone: 228-818-5008
  • Fax: 228-818-5012
Mailing address:
  • Phone: 228-818-5008
  • Fax: 228-818-5012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAU5009697 1339
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21719
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: