Provider Demographics
NPI:1629001524
Name:LOGUE, DREW HENDERSON (MD)
Entity type:Individual
Prefix:DR
First Name:DREW
Middle Name:HENDERSON
Last Name:LOGUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:STE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:1540 FLORIDA AVE
Practice Address - Street 2:STE 212
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4430
Practice Address - Country:US
Practice Address - Phone:209-578-3170
Practice Address - Fax:209-529-4151
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2013-09-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA255191207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27056ZMedicare ID - Type Unspecified
CAA24475Medicare UPIN