Provider Demographics
NPI:1164460069
Name:PARK AVENUE OPHTHALMICS, PLLC
Entity Type:Organization
Organization Name:PARK AVENUE OPHTHALMICS, PLLC
Other - Org Name:ADVANCED EYE CRE OF BAY CN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HASTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-784-3936
Mailing Address - Street 1:2500 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2349
Mailing Address - Country:US
Mailing Address - Phone:850-784-3936
Mailing Address - Fax:850-784-3539
Practice Address - Street 1:2500 W 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2349
Practice Address - Country:US
Practice Address - Phone:850-784-3936
Practice Address - Fax:850-784-3539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38903OtherBCBS FL
FL259391200Medicaid
CM3172OtherMEDICARE RETIRED RAILROAD
FL38903OtherBCBS FL
FLK0862Medicare PIN