Healthcare Provider Details

I. General information

NPI: 1134176274
Provider Name (Legal Business Name): SCOTT WILSON SOUTHARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/30/2022
Certification Date: 07/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 VIRGINIA RANCH RD STE 1B
GARDNERVILLE NV
89410-5732
US

IV. Provider business mailing address

1520 VIRGINIA RANCH RD STE 1B
GARDNERVILLE NV
89410-5732
US

V. Phone/Fax

Practice location:
  • Phone: 530-541-4119
  • Fax: 530-541-3246
Mailing address:
  • Phone: 530-541-4119
  • Fax: 541-813-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG60029
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number6292
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: