Provider Demographics
NPI:1972602910
Name:SOUTHWORTH, SCOTT E (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:E
Last Name:SOUTHWORTH
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 1:140 N UNION AVE STE F-300
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2953
Mailing Address - Country:US
Mailing Address - Phone:801-294-9333
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL DR STE 300
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8925
Practice Address - Country:US
Practice Address - Phone:801-292-1422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT173151-1205208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD20131Medicare UPIN
UTP00349258Medicare PIN
UT000068726Medicare PIN
UT000059621Medicare PIN