Provider Demographics
NPI:1720148356
Name:SOUTHARD, STEPHANIE (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-2430
Mailing Address - Country:US
Mailing Address - Phone:606-340-3251
Mailing Address - Fax:606-348-0618
Practice Address - Street 1:166 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2430
Practice Address - Country:US
Practice Address - Phone:606-340-3251
Practice Address - Fax:606-348-0618
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02809208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64061807Medicaid
KY0687403Medicare PIN