Provider Demographics
NPI:1417128752
Name:EYEWEAR STUDIO
Entity Type:Organization
Organization Name:EYEWEAR STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TYMIAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-785-4419
Mailing Address - Street 1:2650 TAMPA RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-786-8008
Mailing Address - Fax:727-789-3351
Practice Address - Street 1:2650 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-786-8008
Practice Address - Fax:727-789-3351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30547207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1277530001Medicare NSC