Healthcare Provider Details

I. General information

NPI: 1598811580
Provider Name (Legal Business Name): SAN LUIS DIAGNOSTIC MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MONTEREY ST SUITE 210
SAN LUIS OBISPO CA
93401-3102
US

IV. Provider business mailing address

1100 MONTEREY ST SUITE 210
SAN LUIS OBISPO CA
93401-3102
US

V. Phone/Fax

Practice location:
  • Phone: 805-542-9700
  • Fax: 805-542-0584
Mailing address:
  • Phone: 805-542-9700
  • Fax: 805-542-0584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. GAIL L. ROBERTS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 805-542-9700