Provider Demographics
NPI:1497746473
Name:PISMO FAMILY PRACTICE MEDICAL CORPORATION A CA PROF MEDICAL CORP
Entity Type:Organization
Organization Name:PISMO FAMILY PRACTICE MEDICAL CORPORATION A CA PROF MEDICAL CORP
Other - Org Name:PISMO FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:EVE
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-773-0707
Mailing Address - Street 1:575 PRICE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2553
Mailing Address - Country:US
Mailing Address - Phone:805-773-0707
Mailing Address - Fax:805-773-2051
Practice Address - Street 1:575 PRICE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2553
Practice Address - Country:US
Practice Address - Phone:805-773-0707
Practice Address - Fax:805-773-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A0436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC1962153OtherSTATE CORPORATION NUMBER
CAZZZ48888ZOtherBLUE SHIELD GROUP NUMBER
CAGR0080750Medicaid
CAGR0080750Medicaid
CACL581Medicare PIN
CAZZZ48888ZOtherBLUE SHIELD GROUP NUMBER