MEDICARE: LOGAN THOMPSON MITCHELL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3375ATI	OR

General Provider Information

NPI Number	:	1831401967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN THOMPSON MITCHELL O.D.

Provider Business Mailing Address
First Line	:	3325 9TH DR
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-1525
Country	:	US
Telephone Number	:	503-314-3561
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 3RD ST
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-2609
Country	:	US
Telephone Number	:	541-523-5858
Fax Number	:	541-523-7652

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2010
Last Update Date	:	07/06/2010

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