Provider Demographics
NPI:1861661340
Name:HYATT OPTICAL INC
Entity Type:Organization
Organization Name:HYATT OPTICAL INC
Other - Org Name:HYATT OPTICAL INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-384-9141
Mailing Address - Street 1:6800 GULFPORT BLVD S
Mailing Address - Street 2:219
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2163
Mailing Address - Country:US
Mailing Address - Phone:727-384-9141
Mailing Address - Fax:727-347-5108
Practice Address - Street 1:6800 GULFPORT BLVD S
Practice Address - Street 2:219
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-2163
Practice Address - Country:US
Practice Address - Phone:727-384-9141
Practice Address - Fax:727-347-5108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE177332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1180920001Medicare NSC