Provider Demographics
NPI:1619966462
Name:SOUTHWICK, DAVID ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ANDREW
Last Name:SOUTHWICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-2706
Mailing Address - Country:US
Mailing Address - Phone:812-238-4499
Mailing Address - Fax:812-238-4493
Practice Address - Street 1:5969 S ERNEST ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-8111
Practice Address - Country:US
Practice Address - Phone:812-238-4499
Practice Address - Fax:812-238-4493
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001402208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100253000AMedicaid
IN859560Medicare ID - Type Unspecified
IN100253000AMedicaid