Provider Demographics
NPI:1124281902
Name:SOUTHARD, NICHOLAS (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:SOUTHARD
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:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:515-875-9223
Practice Address - Street 1:5950 UNIVERSITY AVE
Practice Address - Street 2:STE 231
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266
Practice Address - Country:US
Practice Address - Phone:515-875-9090
Practice Address - Fax:515-875-9312
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-044022086S0129X
WI55568-0212086S0129X
IA44022086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery