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General NPI Number Information
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NPI Number | 1235550146
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Entity Type | Organization
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Legal Business Name | B. MICHAEL SOUTHAM, OD, PC
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Dates
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Enumeration Date | 12/18/2013
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Last Update Date | 12/18/2013
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Provider Practice Location Address
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Address Line | 3201 LAKESIDE DR
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City | RENO
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State | NV
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Zip | 89509-4830
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Country | US
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Telephone | 775-825-0559
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Fax | 775-829-7918
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Provider Business Mailing Address
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Address Line | 3201 LAKESIDE DR
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City | RENO
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State | NV
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Zip | 89509-4830
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Country | US
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Telephone | 775-825-0559
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Fax | 775-829-7918
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. BRANT MICHAEL SOUTHAM
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Credential | OD
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Telephone | 775-825-0559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 779
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License Number State | NV
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