Provider Demographics
NPI:1619166253
Name:LOGAN, BRENT JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:JUSTIN
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1701 WESTCHESTER DR
Mailing Address - Street 2:STE. 8502
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7008
Mailing Address - Country:US
Mailing Address - Phone:336-802-2400
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:1814 WESTCHESTER DR
Practice Address - Street 2:STE. 203
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7299
Practice Address - Country:US
Practice Address - Phone:336-802-2100
Practice Address - Fax:336-802-2101
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2016-10-25
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Provider Licenses
StateLicense IDTaxonomies
TN504172080P0205X, 208000000X
VA0101254581208000000X, 2080P0205X
NC2007-01471208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology