Provider Demographics
NPI:1720303308
Name:SOUTHGATE, RICHARD DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DOUGLAS
Last Name:SOUTHGATE
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 1:1000 N WESTMORELAND RD # LEVEL3
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:847-535-8500
Mailing Address - Fax:847-535-8499
Practice Address - Street 1:1000 N WESTMORELAND RD # LEVEL3
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:847-535-8500
Practice Address - Fax:847-535-8499
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142231207X00000X
IL036162961207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD184629OtherOR MEDICAL LICENSE