Provider Demographics
NPI:1346365780
Name:SAN LUIS OBISPO PUBLIC HEALTH
Entity Type:Organization
Organization Name:SAN LUIS OBISPO PUBLIC HEALTH
Other - Org Name:AIDS PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:W
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-781-5519
Mailing Address - Street 1:2191 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4534
Mailing Address - Country:US
Mailing Address - Phone:805-781-5500
Mailing Address - Fax:805-781-5543
Practice Address - Street 1:2191 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4534
Practice Address - Country:US
Practice Address - Phone:805-781-5500
Practice Address - Fax:805-781-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG461382083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAYD000340Medicaid
PENDINGMedicare UPIN
CAAYD000340Medicaid