Provider Demographics
NPI:1235550146
Name:B. MICHAEL SOUTHAM, OD, PC
Entity Type:Organization
Organization Name:B. MICHAEL SOUTHAM, OD, PC
Other - Org Name:BLACK ROCK VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
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:775-825-0559
Mailing Address - Street 1:3201 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4830
Mailing Address - Country:US
Mailing Address - Phone:775-825-0559
Mailing Address - Fax:775-829-7918
Practice Address - Street 1:3201 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4830
Practice Address - Country:US
Practice Address - Phone:775-825-0559
Practice Address - Fax:775-829-7918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100533928Medicaid