Healthcare Provider Details

I. General information

NPI: 1427052497
Provider Name (Legal Business Name): JASON SCOT BRODY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MOUNT VERNON HWY SUITE 125
ATLANTA GA
30328-4295
US

IV. Provider business mailing address

1065 JODECO RD
STOCKBRIDGE GA
30281-4953
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-1125
  • Fax: 404-256-1964
Mailing address:
  • Phone: 678-284-6314
  • Fax: 678-284-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036110895
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number063298
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: