Basic Information
| Provider Information | |||||||||
| NPI: | 1639159411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL COAST MATERNAL-FETAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CASA ST | ||||||||
| Address2: | SUITE D-3 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934051883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055462057 | ||||||||
| FaxNumber: | 8057840895 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CASA ST | ||||||||
| Address2: | SUITE D-3 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934051883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055462057 | ||||||||
| FaxNumber: | 8057840895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CEDARS | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055462057 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 2378377 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
No ID Information.