MEDICARE: BUENA VISTA EYE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	9800734	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	012T3	OTHER	NC	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720069693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUENA VISTA EYE PC

Provider Business Mailing Address
First Line	:	1214 REYNOLDA RD
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-1122
Country	:	US
Telephone Number	:	336-723-2555
Fax Number	:	336-723-9007

Provider Business Practice Location Address
First Line	:	1214 REYNOLDA RD
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-1122
Country	:	US
Telephone Number	:	336-723-2555
Fax Number	:	336-723-9007

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. AMY BARTA WALL
Credential	:	MD
Telephone Number	:	336-723-2555

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	11/03/2010

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