Provider Demographics
NPI:1760672729
Name:BRUCE HYATT
Entity Type:Organization
Organization Name:BRUCE HYATT
Other - Org Name:ROLAND PARK VISION SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:IRVIN
Authorized Official - Last Name:HYATT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-243-8884
Mailing Address - Street 1:409 W COLD SPRING LN
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 LN
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTAO749MD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDX328Medicare PIN