Provider Demographics
NPI:1871613281
Name:LOGSTON, JAMES MICHAEL
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:LOGSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 MAHONING AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2039
Mailing Address - Country:US
Mailing Address - Phone:330-719-6284
Mailing Address - Fax:
Practice Address - Street 1:6431 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2039
Practice Address - Country:US
Practice Address - Phone:330-719-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT004922225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1871613281Medicaid
OH2577162Medicaid