Healthcare Provider Details

I. General information

NPI: 1053016592
Provider Name (Legal Business Name): LOGAN DOUGLAS BIRCH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N THANKSGIVING WAY STE 190
LEHI UT
84048-4157
US

IV. Provider business mailing address

3401 N THANKSGIVING WAY STE 190
LEHI UT
84048-4157
US

V. Phone/Fax

Practice location:
  • Phone: 385-454-5027
  • Fax:
Mailing address:
  • Phone: 385-454-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number14295383-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: