Healthcare Provider Details

I. General information

NPI: 1689137143
Provider Name (Legal Business Name): CHAD LOGAN MARTINEZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N 500 E
LOGAN UT
84341-2455
US

IV. Provider business mailing address

1400 N 500 E
LOGAN UT
84341-2455
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-1920
  • Fax:
Mailing address:
  • Phone: 435-716-1920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number12981265-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: