Provider Demographics
NPI:1114042348
Name:HAYYAT, AMJAD MAHMOUD (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:AMJAD
Middle Name:MAHMOUD
Last Name:HAYYAT
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 FORBES CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-1128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1215
Practice Address - Country:US
Practice Address - Phone:802-388-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT028-0000295156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011579Medicaid