Provider Demographics
NPI:1982700969
Name:SOUTHMAYD, ROBERT CHARLES (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHARLES
Last Name:SOUTHMAYD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3062 JOSHUA TREE CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-3800
Mailing Address - Country:US
Mailing Address - Phone:209-244-8101
Mailing Address - Fax:
Practice Address - Street 1:1768 MITCHELL RD STE 301
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2156
Practice Address - Country:US
Practice Address - Phone:209-353-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5298207R00000X
CA20A5298207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA911803606OtherBLUE SHIELD
CA00AX52980Medicaid
CA160038160OtherRAILROAD MEDICARE
CA911803606OtherBLUE SHIELD
CA00AX52980Medicaid