Provider Demographics
NPI:1649267535
Name:SOUTHARD, JOHN K JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:K
Last Name:SOUTHARD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:K
Other - Last Name:SOUTHARD
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1345B WESTGATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2934
Mailing Address - Country:US
Mailing Address - Phone:336-768-1280
Mailing Address - Fax:336-760-8443
Practice Address - Street 1:1345B WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2934
Practice Address - Country:US
Practice Address - Phone:336-768-1280
Practice Address - Fax:336-760-8443
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18576174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013U8Medicaid
SCQ18576Medicaid
NC201439BMedicare PIN
SCQ18576Medicaid
NC89013U8Medicaid