Healthcare Provider Details

I. General information

NPI: 1235799024
Provider Name (Legal Business Name): LOGAN MICHAEL SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 BLUE RIDGE RD STE 100
RALEIGH NC
27607-6462
US

IV. Provider business mailing address

2709 BLUE RIDGE RD STE 100
RALEIGH NC
27607-6462
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-5400
  • Fax:
Mailing address:
  • Phone: 919-782-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number67797
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number2024-01420
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: