Healthcare Provider Details

I. General information

NPI: 1245178441
Provider Name (Legal Business Name): LOGAN BLAISE TACKETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 S I 35 E
DENTON TX
76210-6850
US

IV. Provider business mailing address

128 CENTRAL AVE
PIKEVILLE KY
41501-1354
US

V. Phone/Fax

Practice location:
  • Phone: 940-384-3013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: