Provider Demographics
NPI:1548916000
Name:COOK LOGAN, WANDA (RT,R DMS)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:COOK LOGAN
Suffix:
Gender:F
Credentials:RT,R DMS
Other - Prefix:MS
Other - First Name:WANDA
Other - Middle Name:F
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:19753 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-6333
Mailing Address - Country:US
Mailing Address - Phone:708-250-7108
Mailing Address - Fax:219-841-7004
Practice Address - Street 1:5111 SAULK TRAIL
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471
Practice Address - Country:US
Practice Address - Phone:219-836-4702
Practice Address - Fax:219-841-7004
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1567652085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound