Provider Demographics
NPI:1972695377
Name:SOUTHARD, ROBERT W (NP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1380 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2098
Mailing Address - Country:US
Mailing Address - Phone:631-369-0022
Mailing Address - Fax:631-369-5336
Practice Address - Street 1:1380 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2098
Practice Address - Country:US
Practice Address - Phone:631-369-0022
Practice Address - Fax:631-369-5336
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400418363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS58673Medicare UPIN