Provider Demographics
NPI:1154381333
Name:SOUTHERN, FREDRICK NEWELL (MD)
Entity type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:NEWELL
Last Name:SOUTHERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FREDRICK
Other - Middle Name:NEWELL
Other - Last Name:SOUTHERN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5589 GREENWICH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6565
Mailing Address - Country:US
Mailing Address - Phone:757-437-2882
Mailing Address - Fax:757-502-8800
Practice Address - Street 1:5589 GREENWICH RD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-437-2882
Practice Address - Fax:757-502-8800
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010444232086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV03899765Medicare PIN