Provider Demographics
NPI:1619227675
Name:CUESTA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CUESTA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-547-1255
Mailing Address - Street 1:1555 HIGUERA STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2917
Mailing Address - Country:US
Mailing Address - Phone:805-543-4043
Mailing Address - Fax:805-543-4427
Practice Address - Street 1:171 N SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1328
Practice Address - Country:US
Practice Address - Phone:805-543-4043
Practice Address - Fax:805-543-4427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13933Medicare PIN