Healthcare Provider Details

I. General information

NPI: 1922941178
Provider Name (Legal Business Name): BRODY LOGAN DAVIS MMS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 N MAIN ST STE 101
HIGH POINT NC
27262-7830
US

IV. Provider business mailing address

1137 MARTIN ST
WINSTON SALEM NC
27103-4430
US

V. Phone/Fax

Practice location:
  • Phone: 336-884-4050
  • Fax:
Mailing address:
  • Phone: 540-226-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16700
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: