Healthcare Provider Details

I. General information

NPI: 1295304103
Provider Name (Legal Business Name): JASON KORT WOODY SR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 S GRAND BLVD
SAINT LOUIS MO
63118-3405
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI GARDENS FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 314-328-0144
  • Fax: 314-788-3021
Mailing address:
  • Phone: 305-628-6117
  • Fax: 305-393-5989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024028667
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021024168
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: