Healthcare Provider Details

I. General information

NPI: 1619966462
Provider Name (Legal Business Name): DAVID ANDREW SOUTHWICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5969 S ERNEST ST
TERRE HAUTE IN
47802-8111
US

IV. Provider business mailing address

1606 N 7TH ST
TERRE HAUTE IN
47804-2706
US

V. Phone/Fax

Practice location:
  • Phone: 812-238-4499
  • Fax: 812-238-4493
Mailing address:
  • Phone: 812-238-4499
  • Fax: 812-238-4493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number02001402
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: