Provider Demographics
NPI:1831427160
Name:SOUTHAM, BRANT MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:BRANT
Middle Name:MICHAEL
Last Name:SOUTHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 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
Practice Address - Country:US
Practice Address - Phone:775-825-0559
Practice Address - Fax:775-829-7918
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60235215152W00000X
AZ1727152W00000X
NV779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist