Provider Demographics
NPI:1386806669
Name:SOUTHWORTH, RYAN (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SOUTHWORTH
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 1:1800 E FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5303
Mailing Address - Country:US
Mailing Address - Phone:530-902-3709
Mailing Address - Fax:
Practice Address - Street 1:1800 E. FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122
Practice Address - Country:US
Practice Address - Phone:610-776-4622
Practice Address - Fax:610-776-4622
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005891207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine