Individual
DR. EDWARD G SOUTHWICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3465 S 4155 W, SUITE #1, WEST VALLEY CITY, UT 84120-2076
(801) 966-1403
(801) 964-6478
Mailing address
3465 SOUTH 4155 WEST, SUITE #1, WEST VALLEY CITY, UT 84120-2077
(801) 966-1403
(801) 964-6478
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
156560-1205
UT
207ND0900X
Dermatopathology Physician
156560-1205
UT
207NS0135X
Procedural Dermatology Physician
156560-1205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
071157009
RAILROAD MEDICARE
UT
Enumeration date
01/19/2006
Last updated
08/14/2012
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