Provider Demographics
NPI:1104967090
Name:SOUTHARD, JOHN G (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EDMUNDSON PL
Mailing Address - Street 2:SUITE 312
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4658
Mailing Address - Country:US
Mailing Address - Phone:712-396-4295
Mailing Address - Fax:712-396-4298
Practice Address - Street 1:1 EDMUNDSON PL
Practice Address - Street 2:SUITE 312
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4658
Practice Address - Country:US
Practice Address - Phone:712-396-4295
Practice Address - Fax:712-396-4298
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22453207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1133413Medicaid
IA47244OtherBLUE CROSS BLUE SHIELD
IA1133413Medicaid
IAI6347Medicare ID - Type Unspecified