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NPI Code Detail

MEDICARE: DR. CHARLES C SOUTHERLAND DPM

MEDICARE: DR. CHARLES C SOUTHERLAND DPM
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1213ES0103XFoot & Ankle Surgery Podiatrist9244891-0501UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
19244891-0501OTHERUTMEDICAL LICENSE

General Provider Information

NPI Number : 1306832944
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CHARLES C SOUTHERLAND DPM
Provider Business Mailing Address
First Line : 11300 NE 2ND AVENUE
Second Line :
City : MIAMI SHORES
State : FL
Zip : 33161
Country : US
Telephone Number : 305-693-7287
Fax Number : 305-694-9616
Provider Business Practice Location Address
First Line : 3435 E PONY EXPRESS PKWY STE 140
Second Line :
City : EAGLE MOUNTAIN
State : UT
Zip : 84005-5548
Country : US
Telephone Number : 801-893-8811
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/20/2005
Last Update Date : 04/24/2020

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