Provider Demographics
NPI:1598811580
Name:SAN LUIS DIAGNOSTIC MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SAN LUIS DIAGNOSTIC MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-542-9700
Mailing Address - Street 1:1100 MONTEREY ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3102
Mailing Address - Country:US
Mailing Address - Phone:805-542-9700
Mailing Address - Fax:805-542-0584
Practice Address - Street 1:1100 MONTEREY ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3102
Practice Address - Country:US
Practice Address - Phone:805-542-9700
Practice Address - Fax:805-542-0584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0088380Medicaid
CAZZZ55471ZOtherBLUE SHIELD ID NUMBER
CAGR0088380Medicaid