Provider Demographics
NPI:1992045090
Name:SOUTHARD, MICHELLE MARTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARTIN
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ABBE
Other - Middle Name:MICHELLE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:800 8TH AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2606
Mailing Address - Country:US
Mailing Address - Phone:817-335-6363
Mailing Address - Fax:
Practice Address - Street 1:800 8TH AVE STE 116
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2606
Practice Address - Country:US
Practice Address - Phone:817-335-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020787208200000X, 2086S0122X
TXP4783208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery