Basic Information
| Provider Information | |||||||||
| NPI: | 1568426385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 RIVERWAY PL | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031106768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036687096 | ||||||||
| FaxNumber: | 6036696944 | ||||||||
| Practice Location | |||||||||
| Address1: | 703 RIVERWAY PL | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031106768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036687096 | ||||||||
| FaxNumber: | 6036696944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 10868 | NH | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 01Y002303 NH05 | 01 | NH | ANTHEM-MCH TAX ID | OTHER | 01Y002303NH02 | 01 | NH | BLUE CROSS | OTHER | 2285319 | 01 | NH | AETNA | OTHER | 010868 | 01 | NH | TUFTS | OTHER | 294662 | 01 | NH | CIGNA | OTHER | 30200557 | 05 | NH | MEDICAID |