Provider Demographics
NPI:1528110079
Name:LOGULLO, MARK ANTHONY (D,C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:LOGULLO
Suffix:
Gender:M
Credentials:D,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N BROAD ST
Mailing Address - Street 2:SUITE 19
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1032
Mailing Address - Country:US
Mailing Address - Phone:302-378-5441
Mailing Address - Fax:302-378-3452
Practice Address - Street 1:600 N BROAD ST
Practice Address - Street 2:SUITE 19
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1032
Practice Address - Country:US
Practice Address - Phone:302-378-5441
Practice Address - Fax:302-378-3452
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1999210007111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor