Provider Demographics
NPI:1104888692
Name:SOUTHER, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:SOUTHER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:12420 WARWICK BLVD
Practice Address - Street 2:BLDG. 3 SUITE 4A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3001
Practice Address - Country:US
Practice Address - Phone:757-594-4431
Practice Address - Fax:757-594-2936
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2011-05-17
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Provider Licenses
StateLicense IDTaxonomies
VA0101049650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104888692Medicaid
VA1104888692Medicaid
VA015473R53Medicare PIN
F56842Medicare UPIN