Organization
RETINA SPECIALISTS OF THE CENTRAL COAST INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEREK B. LAURITZEN M.D. (PRESIDENT)
(805) 547-2090
Entity
Organization
Contact information
Practice address
628 CALIFORNIA BLVD, SUITE C, SAN LUIS OBISPO, CA 93401-2542
(805) 547-2090
(805) 547-2095
Mailing address
628 CALIFORNIA BLVD, SUITE C, SAN LUIS OBISPO, CA 93401-2542
(805) 547-2090
(805) 547-2095
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
C3049777
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
613177600
OWCP
—
01
—
C3049777
CA STATE LICENSE
CA
01
—
ZZZ50256Y
BLUE SHIELD OF CALIFORNIA
CA
Enumeration date
12/07/2007
Last updated
11/18/2009
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