Provider Demographics
NPI:1720069693
Name:BUENA VISTA EYE PC
Entity Type:Organization
Organization Name:BUENA VISTA EYE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:BARTA
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-723-2555
Mailing Address - Street 1:1214 REYNOLDA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1122
Mailing Address - Country:US
Mailing Address - Phone:336-723-2555
Mailing Address - Fax:336-723-9007
Practice Address - Street 1:1214 REYNOLDA RD
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-1122
Practice Address - Country:US
Practice Address - Phone:336-723-2555
Practice Address - Fax:336-723-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800734207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012T3OtherBCBS
NC89012T3Medicaid
NC89012T3Medicaid
NC4301550001Medicare NSC
G87006Medicare UPIN