Healthcare Provider Details

I. General information

NPI: 1982069233
Provider Name (Legal Business Name): WOODLAKE PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 WOODLAKE DR 200
CHESTERFIELD MO
63017-5740
US

IV. Provider business mailing address

1585 WOODLAKE DR 200
CHESTERFIELD MO
63017-5740
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-7430
  • Fax: 314-434-8768
Mailing address:
  • Phone: 314-434-7430
  • Fax: 314-434-8768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2015014632
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000414
License Number StateMO

VIII. Authorized Official

Name: HOWARD JAFFE
Title or Position: OWNER/PODIATRIST
Credential: DPM
Phone: 314-434-7430