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General NPI Number Information
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NPI Number | 1538235601
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Entity Type | Individual
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Provider Name | DOUGLAS B SOUTHWORTH MD
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Gender | Male
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 02/04/2016
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Provider Practice Location Address
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Address Line | 109 BEE STREET CHARLESTON VAMC
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City | CHARLESTON
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State | SC
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Zip | 29401-0000
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Country | US
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Telephone | 843-477-0177
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Fax | 843-232-2441
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Provider Business Mailing Address
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Address Line | 109 BEE STREET CHARLESTON VAMC
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City | CHARLESTON
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State | SC
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Zip | 29401-0000
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Country | US
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Telephone | 843-477-0177
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Fax | 843-232-2441
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 7700
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License Number State | NH
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 42-0008157
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License Number State | VT
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