Healthcare Provider Details

I. General information

NPI: 1750852810
Provider Name (Legal Business Name): ENT MEDICAL AND SURGICAL CARE A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CASA ST STE B
SAN LUIS OBISPO CA
93405-8803
US

IV. Provider business mailing address

100 CASA ST STE B
SAN LUIS OBISPO CA
93405-8803
US

V. Phone/Fax

Practice location:
  • Phone: 805-439-3250
  • Fax: 888-359-6465
Mailing address:
  • Phone: 805-439-3250
  • Fax: 888-359-6465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID JACKSON LEVIN
Title or Position: CEO
Credential: MD
Phone: 805-439-3250