Healthcare Provider Details

I. General information

NPI: 1497495295
Provider Name (Legal Business Name): LOGAN PATRICK DAINES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 W KILBOURN AVE STE 200
MILWAUKEE WI
53233-1325
US

IV. Provider business mailing address

1218 W KILBOURN AVE STE 200
MILWAUKEE WI
53233-1325
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-7370
  • Fax: 414-219-7967
Mailing address:
  • Phone: 414-219-7370
  • Fax: 414-219-7967

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 Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number81909-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: