Provider Demographics
NPI:1548323140
Name:LOGAN, MARK (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 POND ST STE 9
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-6854
Mailing Address - Country:US
Mailing Address - Phone:781-843-8187
Mailing Address - Fax:
Practice Address - Street 1:340 WOOD RD
Practice Address - Street 2:STE 303
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2404
Practice Address - Country:US
Practice Address - Phone:781-843-8187
Practice Address - Fax:781-899-9233
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1465111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT-91233Medicare UPIN
MAY36083Medicare PIN