Provider Demographics
NPI:1497067060
Name:SOUTHALL, LORENZO (CS)
Entity Type:Individual
Prefix:MR
First Name:LORENZO
Middle Name:
Last Name:SOUTHALL
Suffix:
Gender:M
Credentials:CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 SCHILLER ST.
Mailing Address - Street 2:#20
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-2995
Mailing Address - Country:US
Mailing Address - Phone:608-341-8249
Mailing Address - Fax:
Practice Address - Street 1:555 SCHILLER ST.
Practice Address - Street 2:#20
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2995
Practice Address - Country:US
Practice Address - Phone:608-341-8249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program