Provider Demographics
NPI:1265499347
Name:SOUTHWORTH, WILLIAM F (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:F
Last Name:SOUTHWORTH
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 1:1151 HAZEL LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640
Mailing Address - Country:US
Mailing Address - Phone:573-747-1777
Mailing Address - Fax:571-747-1077
Practice Address - Street 1:1151 HAZEL LANE
Practice Address - Street 2:
Practice Address - City:FARMINGTON, MO
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-747-1777
Practice Address - Fax:573-747-1077
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060822207RC0000X
MOR7100207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00646568OtherRR PTAN
MO000013185OtherMEDICARE GROUP PTAN
MO131850001OtherMEDICARE PTAN
MO1881863009OtherGROUP NPI
MOCI7050OtherRR GROUP
MOP00847517OtherRAILROAD MEDICARE
MO1265499347Medicaid
MO147540026Medicare PIN
MO1881863009OtherGROUP NPI