Provider Demographics
NPI:1578799102
Name:SOUTHARD, EDWARD JAMES (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JAMES
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 1:9077 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3405
Mailing Address - Country:US
Mailing Address - Phone:772-335-4770
Mailing Address - Fax:772-335-4133
Practice Address - Street 1:9077 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3405
Practice Address - Country:US
Practice Address - Phone:772-398-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME141008207X00000X
NY260267207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery