Healthcare Provider Details

I. General information

NPI: 1245220144
Provider Name (Legal Business Name): JASON A. LOGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 01/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 S LEWIS AVE
TULSA OK
74136-6836
US

IV. Provider business mailing address

210 JAMES RD
BOLIVAR TN
38008-1110
US

V. Phone/Fax

Practice location:
  • Phone: 731-228-9778
  • Fax: 918-493-7813
Mailing address:
  • Phone: 731-658-5421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number22922
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22922
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: