Provider Demographics
NPI:1316137052
Name:SOUTH, BETHANY ANN (OD)
Entity type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:ANN
Last Name:SOUTH
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:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422-0728
Mailing Address - Country:US
Mailing Address - Phone:601-764-2120
Mailing Address - Fax:
Practice Address - Street 1:16 SOUTH 16TH ST
Practice Address - Street 2:
Practice Address - City:BAY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39422
Practice Address - Country:US
Practice Address - Phone:601-764-2120
Practice Address - Fax:601-764-3410
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13338152W00000X
MS831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13338OtherCALIFORNIA BOARD OF OPTOM
MS831OtherOPTOMETRY LICENSE