Provider Demographics
NPI:1942462189
Name:LOGAN BUNDY MD
Entity type:Organization
Organization Name:LOGAN BUNDY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-524-6700
Mailing Address - Street 1:533 SESPE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015
Mailing Address - Country:US
Mailing Address - Phone:805-524-6700
Mailing Address - Fax:805-524-6707
Practice Address - Street 1:533 SESPE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015-1985
Practice Address - Country:US
Practice Address - Phone:805-524-6700
Practice Address - Fax:805-524-6707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30561173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE96477Medicare UPIN