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General NPI Number Information
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NPI Number | 1306133210
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Entity Type | Individual
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Provider Name | LOGAN ROBERT VIDAL DO
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Gender | Male
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Dates
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Enumeration Date | 06/30/2011
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Last Update Date | 12/17/2019
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Provider Practice Location Address
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Address Line | VAMC 3350 LA JOLLA VILLAGE DR
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City | SAN DIEGO
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State | CA
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Zip | 92161-0001
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Country | US
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Telephone | 858-552-8585
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Fax |
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Provider Business Mailing Address
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Address Line | 300 W MAY ST
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City | MARENGO
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State | IA
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Zip | 52301-1261
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R-9308
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4347
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS12575
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License Number State | FL
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