Provider Demographics
NPI:1649231101
Name:HYATT, BRUCE IRVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:IRVIN
Last Name:HYATT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W COLD SPRING LANE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2845
Mailing Address - Country:US
Mailing Address - Phone:410-243-8884
Mailing Address - Fax:410-243-5656
Practice Address - Street 1:409 W COLD SPRING LANE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2845
Practice Address - Country:US
Practice Address - Phone:410-243-8884
Practice Address - Fax:410-243-5656
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-11-18
Deactivation Date:2007-12-17
Deactivation Code:
Reactivation Date:2008-02-29
Provider Licenses
StateLicense IDTaxonomies
MDTAO749152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD158700500Medicaid
T77360Medicare UPIN
MD158700500Medicaid