Provider Demographics
NPI:1154527547
Name:SOUTHARD, ANDREW GARRY (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GARRY
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 1:2963 E COPPER POINT DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9055
Mailing Address - Country:US
Mailing Address - Phone:208-322-1730
Mailing Address - Fax:208-322-1731
Practice Address - Street 1:2963 E COPPER POINT DR
Practice Address - Street 2:SUITE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9055
Practice Address - Country:US
Practice Address - Phone:208-322-1730
Practice Address - Fax:208-322-1731
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11238207P00000X
NMRS20070377207P00000X
ORMD183581207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-11238OtherLICENSE
NMRS20070377OtherTRAINING