Provider Demographics
NPI:1659321107
Name:SOUTHERLAND, JOE TALTSON (DPM)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:TALTSON
Last Name:SOUTHERLAND
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W ARBROOK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-3174
Mailing Address - Country:US
Mailing Address - Phone:817-467-1990
Mailing Address - Fax:817-466-8737
Practice Address - Street 1:400 W ARBROOK BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3174
Practice Address - Country:US
Practice Address - Phone:817-467-1990
Practice Address - Fax:817-466-8737
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1473213E00000X
GAPOD000709213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F8971OtherBCBS
TX8770B6Medicare PIN
TX8F21964Medicare PIN
TX8F8971Medicare ID - Type Unspecified
TX8F8971OtherBCBS
TX0889900002Medicare NSC