Provider Demographics
NPI:1437233962
Name:JOHN K. SOUTHARD, JR., M.D., P.A.
Entity type:Organization
Organization Name:JOHN K. SOUTHARD, JR., M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:336-768-1280
Mailing Address - Street 1:1345 WESTGATE CENTER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3040
Mailing Address - Country:US
Mailing Address - Phone:336-768-1280
Mailing Address - Fax:336-760-8443
Practice Address - Street 1:1345 WESTGATE CENTER DR
Practice Address - Street 2:SUITE B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3040
Practice Address - Country:US
Practice Address - Phone:336-768-1280
Practice Address - Fax:336-760-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18576174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013U8Medicaid
NC89013U8Medicaid