Provider Demographics
NPI:1306857271
Name:SOUTHARD, FRED M (DC)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:M
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 NW WASHINGTON BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-6382
Mailing Address - Country:US
Mailing Address - Phone:513-868-0978
Mailing Address - Fax:513-868-3014
Practice Address - Street 1:860 NW WASHINGTON BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-6382
Practice Address - Country:US
Practice Address - Phone:513-868-0978
Practice Address - Fax:513-868-3014
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH720111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0383599Medicaid
OH0445761Medicare ID - Type Unspecified
OH0383599Medicaid