Provider Demographics
NPI:1134176274
Name:SOUTHARD, SCOTT WILSON (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILSON
Last Name:SOUTHARD
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 1:1520 VIRGINIA RANCH RD STE 1B
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5732
Mailing Address - Country:US
Mailing Address - Phone:530-541-4119
Mailing Address - Fax:541-813-2833
Practice Address - Street 1:1520 VIRGINIA RANCH RD STE 1B
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5732
Practice Address - Country:US
Practice Address - Phone:530-541-4119
Practice Address - Fax:530-541-3246
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60029207X00000X
NV6292207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002003053Medicaid
CA00G600291Medicaid
CA00G600290Medicare PIN
NVBY642ZMedicare PIN
CA00G600291Medicaid
NV002003053Medicaid