Provider Demographics
NPI:1811330806
Name:OFFUTT, CORY LS (MD)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:LS
Last Name:OFFUTT
Suffix:
Gender:
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:PO BOX 959318
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9318
Mailing Address - Country:US
Mailing Address - Phone:573-885-6600
Mailing Address - Fax:573-885-6610
Practice Address - Street 1:102 OZARK DR STE B
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1664
Practice Address - Country:US
Practice Address - Phone:573-885-6600
Practice Address - Fax:573-885-6610
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2015002436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1811330806Medicaid
MO26D0889777OtherCLIA
MO268535Medicare Oscar/Certification
MO501010015Medicare PIN
MO268653Medicare Oscar/Certification
MO121690019Medicare PIN
MO1811330806Medicaid
MOMA1297051Medicare PIN