Provider Demographics
NPI:1356466270
Name:SOUTHAMMAVONG, KHAMMANY (OD)
Entity Type:Individual
Prefix:DR
First Name:KHAMMANY
Middle Name:
Last Name:SOUTHAMMAVONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4082 TRISHA TRL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3460
Mailing Address - Country:US
Mailing Address - Phone:804-405-6401
Mailing Address - Fax:
Practice Address - Street 1:1420 PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229
Practice Address - Country:US
Practice Address - Phone:804-741-8901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001556152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist