Provider Demographics
NPI:1780379172
Name:WODLEY, JASON (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WODLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 COLD SPRING RD APT 105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-1960
Mailing Address - Country:US
Mailing Address - Phone:818-300-6509
Mailing Address - Fax:
Practice Address - Street 1:3200 COLD SPRING RD APT 105
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1960
Practice Address - Country:US
Practice Address - Phone:818-300-6509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN1780379172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program