Provider Demographics
NPI:1942422167
Name:SOUTHAM, JODI (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:SOUTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 E 300 S APT 9
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2672
Mailing Address - Country:US
Mailing Address - Phone:202-746-0089
Mailing Address - Fax:
Practice Address - Street 1:590 S WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-587-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186754207X00000X
UT7618740-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery