Provider Demographics
NPI:1235412784
Name:B MICHAEL SOUTHAM O D PC
Entity Type:Organization
Organization Name:B MICHAEL SOUTHAM O D PC
Other - Org Name:B. MICHAEL SOUTHAM, O.D., PC/ FAMILY VISION CARE OF CENTRAL WASHINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SOUTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-689-2342
Mailing Address - Street 1:123 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0578
Mailing Address - Country:US
Mailing Address - Phone:509-689-2342
Mailing Address - Fax:
Practice Address - Street 1:123 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812-0578
Practice Address - Country:US
Practice Address - Phone:509-689-2342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60235215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty