Provider Demographics
NPI:1104931906
Name:SOUTHERS, DONNA G (PA)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:G
Last Name:SOUTHERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-1030
Mailing Address - Country:US
Mailing Address - Phone:304-431-9998
Mailing Address - Fax:304-425-0782
Practice Address - Street 1:904 HARRISON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3011
Practice Address - Country:US
Practice Address - Phone:304-431-7100
Practice Address - Fax:304-431-7112
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP80065Medicare UPIN
WVNAPA20551Medicare PIN