Provider Demographics
NPI:1306825153
Name:SOUTHARD, ERIC R (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
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 1:6000 N BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-5102
Mailing Address - Country:US
Mailing Address - Phone:716-834-4266
Mailing Address - Fax:716-834-6255
Practice Address - Street 1:6000 N BAILEY AVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-5102
Practice Address - Country:US
Practice Address - Phone:716-834-4266
Practice Address - Fax:716-834-6255
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184767207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0409761OtherIHA
NY145445BJOtherPREFERRED CARE
NY040426001983OtherFIDELIS
NY01355022Medicaid
NY00010170803OtherUNIVERA
NY000511558004OtherBC/BS
NY0409761OtherIHA
F41674Medicare UPIN