Healthcare Provider Details

I. General information

NPI: 1659321107
Provider Name (Legal Business Name): JOE TALTSON SOUTHERLAND DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/18/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 GORDON RD SUITE 104
JASPER GA
30143
US

IV. Provider business mailing address

400 W ARBROOK BLVD SUITE 201
ARLINGTON TX
76014-3174
US

V. Phone/Fax

Practice location:
  • Phone: 770-999-0804
  • Fax: 770-999-0814
Mailing address:
  • Phone: 817-467-1990
  • Fax: 817-466-8737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1473
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD000709
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: