Provider Demographics
NPI:1093178915
Name:SOUTHARD, RYAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHAEL
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 UNITED DR STE 410
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-7826
Mailing Address - Country:US
Mailing Address - Phone:501-358-6892
Mailing Address - Fax:501-358-9894
Practice Address - Street 1:625 UNITED DR STE 410
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7826
Practice Address - Country:US
Practice Address - Phone:501-358-6892
Practice Address - Fax:501-358-6894
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-12104208000000X
SC82349208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty