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General NPI Number Information
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NPI Number | 1508380031
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Entity Type | Organization
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Legal Business Name | CENTRAL COAST EYE SURGERY, INC., A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 07/26/2017
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Last Update Date | 03/24/2025
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Provider Practice Location Address
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Address Line | 941 CALIFORNIA BLVD
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401
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Country | US
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Telephone | 805-544-0006
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Fax | 877-843-9745
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Provider Business Mailing Address
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Address Line | 941 CALIFORNIA BLVD
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-2905
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Country | US
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Telephone | 805-544-0006
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DEREK B. LAURITZEN
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Credential | M.D.
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Telephone | 805-544-0006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number | G77319
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License Number State | CA
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