Provider Demographics
NPI:1316934664
Name:SOUDER, BOB T (MD)
Entity type:Individual
Prefix:
First Name:BOB
Middle Name:T
Last Name:SOUDER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WINDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-8835
Mailing Address - Country:US
Mailing Address - Phone:731-343-1512
Mailing Address - Fax:
Practice Address - Street 1:18 WINDWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-8835
Practice Address - Country:US
Practice Address - Phone:731-661-0086
Practice Address - Fax:731-661-0281
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8762207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3172171Medicaid
A56277518OtherDEA
B03513Medicare UPIN
TN3172171Medicaid