Provider Demographics
NPI:1750852810
Name:ENT MEDICAL AND SURGICAL CARE A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ENT MEDICAL AND SURGICAL CARE A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-439-3250
Mailing Address - Street 1:100 CASA ST STE B
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-8803
Mailing Address - Country:US
Mailing Address - Phone:805-439-3250
Mailing Address - Fax:888-359-6465
Practice Address - Street 1:100 CASA ST STE B
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-8803
Practice Address - Country:US
Practice Address - Phone:805-439-3250
Practice Address - Fax:888-359-6465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Single Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty