Healthcare Provider Details

I. General information

NPI: 1649267535
Provider Name (Legal Business Name): JOHN K SOUTHARD JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN K. SOUTHARD JR. M.D.

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345B WESTGATE CENTER DR
WINSTON-SALEM NC
27103-2934
US

IV. Provider business mailing address

1345B WESTGATE CENTER DR
WINSTON-SALEM NC
27103-2934
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-1280
  • Fax: 336-760-8443
Mailing address:
  • Phone: 336-768-1280
  • Fax: 336-760-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number18576
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number18576
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: