Provider Demographics
NPI:1902834054
Name:LOGIUDICE, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:LOGIUDICE
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 1:29409 S WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:RANCHO POLOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275
Mailing Address - Country:US
Mailing Address - Phone:310-832-4225
Mailing Address - Fax:310-831-4860
Practice Address - Street 1:29409 S WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:RANCHO POLOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275
Practice Address - Country:US
Practice Address - Phone:310-832-4225
Practice Address - Fax:310-831-4860
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG18670208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A40390Medicare UPIN
G18670AMedicare ID - Type Unspecified