Healthcare Provider Details

I. General information

NPI: 1265499347
Provider Name (Legal Business Name): WILLIAM F SOUTHWORTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 HAZEL LANE
FARMINGTON, MO MO
63640
US

IV. Provider business mailing address

1151 HAZEL LN
FARMINGTON MO
63640
US

V. Phone/Fax

Practice location:
  • Phone: 573-747-1777
  • Fax: 573-747-1077
Mailing address:
  • Phone: 573-747-1777
  • Fax: 571-747-1077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036060822
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR7100
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: