Provider Demographics
NPI:1043370125
Name:LOGAN, JERRY W (OD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:LOGAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-5867
Mailing Address - Country:US
Mailing Address - Phone:765-966-2661
Mailing Address - Fax:765-965-4789
Practice Address - Street 1:2519 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-5867
Practice Address - Country:US
Practice Address - Phone:765-966-2661
Practice Address - Fax:765-965-4789
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001503B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN967410Medicare ID - Type Unspecified
INT35261Medicare UPIN