Provider Demographics
NPI:1437120730
Name:SOUTHWORTH, STEPHEN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ROBERT
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 1:499 GLOSTER CREEK VLG STE G1
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4751
Mailing Address - Country:US
Mailing Address - Phone:662-377-2663
Mailing Address - Fax:662-377-6706
Practice Address - Street 1:499 GLOSTER CREEK VLG STE G1
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4751
Practice Address - Country:US
Practice Address - Phone:662-377-2663
Practice Address - Fax:662-377-6706
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16972207XS0114X, 207XX0004X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123102Medicaid
MSE89305Medicare UPIN
MS200000400Medicare ID - Type Unspecified