Individual
SAMUEL LYNN SOUTHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1034 N 500 W, PROVO, UT 84604-3380
(801) 357-7850
(801) 357-7626
Mailing address
1034 N 500 W, PROVO, UT 84604-3380
(801) 357-7850
(801) 357-7626
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
12285899-1205
UT
2085R0202X
Diagnostic Radiology Physician
Primary
2005-0536
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
76673855
—
NM
Enumeration date
06/10/2006
Last updated
06/10/2021
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