Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 036-113313 | IL |
Y | 2080P0208X | Pediatric Infectious Diseases | 036-113313 | IL |
NPI | 1558517144 |
---|---|
Provider Name | Dr. Latania K. Logan |
First Address | Chicago, IL 60612-3841 |
Second Address | Chicago, IL 60612-3841 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2008 |
Last Update Date | 12/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036-113313 | STATE LICENSE NUMBER (01) | IL |
336-074676 | STATE LICENSE, CONTROLLED SUBSTANCE (01) | IL |