Healthcare Provider Details

I. General information

NPI: 1720069693
Provider Name (Legal Business Name): BUENA VISTA EYE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 REYNOLDA RD SUITE A
WINSTON SALEM NC
27104-1122
US

IV. Provider business mailing address

1214 REYNOLDA RD SUITE A
WINSTON SALEM NC
27104-1122
US

V. Phone/Fax

Practice location:
  • Phone: 336-723-2555
  • Fax: 336-723-9007
Mailing address:
  • Phone: 336-723-2555
  • Fax: 336-723-9007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number9800734
License Number StateNC

VIII. Authorized Official

Name: MRS. AMY BARTA WALL
Title or Position: PRESIDENT
Credential: MD
Phone: 336-723-2555