Healthcare Provider Details

I. General information

NPI: 1285196436
Provider Name (Legal Business Name): LOGAN DANIELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 VAN WYCK EXPY
RICHMOND HILL NY
11418-2897
US

IV. Provider business mailing address

3415 N CENTURY OAK CIR
OAKLAND MI
48363-2645
US

V. Phone/Fax

Practice location:
  • Phone: 516-949-7973
  • Fax:
Mailing address:
  • Phone: 248-978-6857
  • 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 StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number317791-01
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301506581
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: