MEDICARE: PACIFIC EYE SURGEONS, A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier
2	207W00000X	Ophthalmology Physician	2685147	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC7249	OTHER		RR MEDICARE GRP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	602017000	OTHER		USDL PIN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	ZZZ09808Z	OTHER	CA	BLUE SHIELD OF CA GRP PIN

General Provider Information

NPI Number	:	1548262751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC EYE SURGEONS, A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	3165 BROAD ST
Second Line	:	SUITE 112
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-6778
Country	:	US
Telephone Number	:	805-545-7881
Fax Number	:	805-548-8785

Provider Business Practice Location Address
First Line	:	3855 BROAD ST STE B
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7109
Country	:	US
Telephone Number	:	805-545-8100
Fax Number	:

Authorized Official
Title or Position	:	CHIEF REVENUE OFFICER
Name	:	CLIFTON CHAD BAZHAW
Credential	:
Telephone Number	:	214-893-0471

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	02/10/2026

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Directions to “PACIFIC EYE SURGEONS, A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION ” Practice Location

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