Provider Demographics
NPI:1063608883
Name:SOUTHARD, STEPHEN TIMONTHY
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:TIMONTHY
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 EPPERSON DR
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-2104
Mailing Address - Country:US
Mailing Address - Phone:501-843-2854
Mailing Address - Fax:
Practice Address - Street 1:102 EPPERSON DR
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-2104
Practice Address - Country:US
Practice Address - Phone:501-843-2854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-16
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR61105146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant