Healthcare Provider Details

I. General information

NPI: 1316934664
Provider Name (Legal Business Name): BOB T SOUDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 WINDWOOD DR
JACKSON TN
38305-8835
US

IV. Provider business mailing address

18 WINDWOOD DR
JACKSON TN
38305-8835
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-0086
  • Fax: 731-661-0281
Mailing address:
  • Phone: 731-343-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number8762
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: