Provider Demographics
NPI:1427052497
Name:BRODY, JASON SCOT (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SCOT
Last Name:BRODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 JODECO RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4953
Mailing Address - Country:US
Mailing Address - Phone:678-284-6314
Mailing Address - Fax:678-284-6282
Practice Address - Street 1:800 MOUNT VERNON HWY
Practice Address - Street 2:SUITE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4295
Practice Address - Country:US
Practice Address - Phone:404-256-1125
Practice Address - Fax:404-256-1964
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110895174400000X
GA063298207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA1603Medicaid
SC1522OtherMEDICARE ID
SCPA1603Medicaid
SC1522OtherMEDICARE ID