Healthcare Provider Details

I. General information

NPI: 1831161611
Provider Name (Legal Business Name): JONATHAN PETER SOUTHWORTH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 09/28/2007

III. Provider practice location address

1 WEST LAKESHORE DRIVE SUITE 100
BIRMINGHAM AL
35209-7271
US

IV. Provider business mailing address

1 WEST LAKESHORE DRIVE SUITE 100
BIRMINGHAM AL
35209-7271
US

V. Phone/Fax

Practice location:
  • Phone: 205-930-2950
  • Fax: 205-930-2957
Mailing address:
  • Phone: 205-930-2950
  • Fax: 205-930-2957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO780
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: