Individual
DR. THEODORE P. LOGAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
12 UNION ST, ROCKLAND, ME 04841-2739
(207) 701-4400
(207) 701-4487
Mailing address
300 SOUTHBOROUGH DR, SUITE 201, SOUTH PORTLAND, ME 04106-6914
(207) 661-2018
(207) 661-2033
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
012617
ME
2084A0401X
Addiction Medicine (Psychiatry & Neurology) Physician
MD12617
ME
2084P0800X
Psychiatry Physician
Primary
MD12617
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
047853
ANTHEM STAR NUMBER
ME
05
—
255750099
—
ME
Enumeration date
06/21/2005
Last updated
03/21/2017
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