Provider Demographics
NPI:1306995170
Name:SOUTHARD, LUZBELLA M (MD)
Entity type:Individual
Prefix:
First Name:LUZBELLA
Middle Name:M
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ROSS AVE
Mailing Address - Street 2:BASEMENT LEFT
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1545
Mailing Address - Country:US
Mailing Address - Phone:508-376-0114
Mailing Address - Fax:508-376-9592
Practice Address - Street 1:14 ROSS AVE
Practice Address - Street 2:BASEMENT LEFT
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1545
Practice Address - Country:US
Practice Address - Phone:508-376-0114
Practice Address - Fax:508-376-9592
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA41938207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA738314OtherTUFTS HEALTH CARE
MA0182842Medicaid
MA6274OtherHARVARD PILGRIM HEALTHCAR
MA0182842Medicaid
MA6274OtherHARVARD PILGRIM HEALTHCAR