Healthcare Provider Details

I. General information

NPI: 1619227675
Provider Name (Legal Business Name): CUESTA MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 N SANTA ROSA ST
SAN LUIS OBISPO CA
93405-1328
US

IV. Provider business mailing address

1555 HIGUERA STREET
SAN LUIS OBISPO CA
93401-2917
US

V. Phone/Fax

Practice location:
  • Phone: 805-543-4043
  • Fax: 805-543-4427
Mailing address:
  • Phone: 805-543-4043
  • Fax: 805-543-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: BARBARA M LANDIS
Title or Position: CONTRACTS MANAGER
Credential:
Phone: 805-547-1255