B. Michael Southam, OD, PC

Primary specialty

OptometristTaxonomy code 152W00000X

License

779 Issued in NV

Legal business name

B. MICHAEL SOUTHAM, OD, PC

Doing business as

Black Rock Vision Center

Practice address

3201 Lakeside Dr
Reno, NV 89509-4830

Phone

(775) 825-0559

Fax

(775) 829-7918

NPI assigned

Dec 18, 2013

Last updated

Dec 18, 2013By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Brant Michael Southam, ODNPI 1831427160

Title

Owner/President

Phone

(775) 825-0559

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Black Rock Vision Center Doing business as

Medicare fee-for-service enrollment

Enrolled in NV

Enrollment records 1

Locations

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

• B. Michael Southam, OD, PC

  dba Black Rock Vision Center

  • Optometrist
  • Winnemucca, NV
  • NPI 1912562596
  NPPES parent name

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Brant Michael Southam, O.D.

  • Optometrist
  • Reno, NV
  • NPI 1831427160
  Medicare reassignment NPD Authorized official
• Corom Dumayne Eisley, OD

  • Optometrist
  • Sparks, NV
  • NPI 1568957744
  Medicare reassignment NPD
• Shaune Wallace, OD

  • Optometrist
  • Elko, NV
  • NPI 1467550335
  Medicare reassignment NPD
• Rylee Marie Ziegler, OD

  • Optometrist
  • Reno, NV
  • NPI 1861273096
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1387324800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1387324800000",
    "number": "1235550146",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3201 LAKESIDE DR",
            "city": "RENO",
            "state": "NV",
            "postal_code": "895094830",
            "telephone_number": "775-825-0559",
            "fax_number": "775-829-7918"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3201 LAKESIDE DR",
            "city": "RENO",
            "state": "NV",
            "postal_code": "895094830",
            "telephone_number": "775-825-0559",
            "fax_number": "775-829-7918"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "B. MICHAEL SOUTHAM, OD, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-18",
        "last_updated": "2013-12-18",
        "status": "A",
        "authorized_official_last_name": "SOUTHAM",
        "authorized_official_first_name": "BRANT",
        "authorized_official_middle_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER/PRESIDENT",
        "authorized_official_telephone_number": "775-825-0559",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NV",
            "license": "779",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100533928",
            "state": "NV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Black Rock Vision Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Gina Azevedo
• Tara J Azevedo
• Mohammad Azim, DO
• Sadra Azizi-Ghannad, M.D.
• B Ortho LLC (B Ortho)
• Vagik H Babakhanian, PH.D.
• Charisse Ruth-Anne Babcock
• Nikola Babovic, M.D.
• Veer R Babu, MD
• Chelsea Baca

• Optometrist in Reno, NV
• Providers in Reno, NV by specialty
• Optometrist in Nevada

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.