Provider Demographics
NPI:1912562596
Name:B. MICHAEL SOUTHAM, OD, PC
Entity Type:Organization
Organization Name:B. MICHAEL SOUTHAM, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:625 SHEEHAN ST APT E
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-3675
Practice Address - Country:US
Practice Address - Phone:775-625-4733
Practice Address - Fax:775-625-4735
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:B. MICHAEL SOUTHAM OD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty