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Organization
PISMO FAMILY PRACTICE MEDICAL CORPORATION A CA PROF MEDICAL CORP
Active
Organization
PISMO FAMILY PRACTICE MEDICAL CORPORATION A CA PROF MEDICAL CORP
Active
Other names
Pismo Family Practice
Organization subpart
No
Provider details
NPI number
Authorized official
DR. WENDY EVE WEISS D.O. (PRESIDENT)
(805) 773-0707
Entity
Organization
Contact information
Practice address
575 PRICE ST, SUITE 101, PISMO BEACH, CA 93449-2553
(805) 773-0707
(805) 773-2051
Mailing address
575 PRICE ST, SUITE 101, PISMO BEACH, CA 93449-2553
(805) 773-0707
(805) 773-2051
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
20A0436
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C1962153
STATE CORPORATION NUMBER
CA
05
—
GR0080750
—
CA
01
—
ZZZ48888Z
BLUE SHIELD GROUP NUMBER
CA
Enumeration date
10/31/2005
Last updated
01/25/2016
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