Healthcare Provider Details

I. General information

NPI: 1568040947
Provider Name (Legal Business Name): MATTHEW DAVID LOGAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10635 PARK RD STE I
CHARLOTTE NC
28210-8408
US

IV. Provider business mailing address

5960 FAIRVIEW RD STE 500
CHARLOTTE NC
28210-3113
US

V. Phone/Fax

Practice location:
  • Phone: 704-495-6334
  • Fax:
Mailing address:
  • Phone: 704-495-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025-02044
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: