Provider Demographics
NPI:1609871573
Name:LOGAN, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARRISH ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1727
Mailing Address - Country:US
Mailing Address - Phone:585-394-6070
Mailing Address - Fax:585-394-3068
Practice Address - Street 1:201 PARRISH ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1727
Practice Address - Country:US
Practice Address - Phone:585-394-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089645207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010089546OtherEXCELLUS BLUE CHOICE
NY1360OtherEXCELLUS BLUE SHIELD
NY100497AAOtherPREFERRED CARE AL
NY00025452201OtherUNIVERA
NY030001160OtherRAILROAD MEDICARE
NY100497DTOtherPREFERRED CARE PA
NY5176319OtherAETNA
NY00025452201OtherUNIVERA
NYD74846Medicare UPIN