Provider Demographics
NPI:1619957156
Name:SOUTHWICK, EDWARD G (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:G
Last Name:SOUTHWICK
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 1:3465 SOUTH 4155 WEST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2077
Mailing Address - Country:US
Mailing Address - Phone:801-966-1403
Mailing Address - Fax:801-964-6478
Practice Address - Street 1:3465 S 4155 W
Practice Address - Street 2:SUITE #1
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2076
Practice Address - Country:US
Practice Address - Phone:801-966-1403
Practice Address - Fax:801-964-6478
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT156560-1205207N00000X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT071157009OtherRAILROAD MEDICARE
UT071157009OtherRAILROAD MEDICARE
UT000000571Medicare ID - Type Unspecified