Provider Demographics
NPI:1821271248
Name:RETINA SPECIALISTS OF THE CENTRAL COAST INC
Entity Type:Organization
Organization Name:RETINA SPECIALISTS OF THE CENTRAL COAST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAURITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-547-2090
Mailing Address - Street 1:628 CALIFORNIA BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2542
Mailing Address - Country:US
Mailing Address - Phone:805-547-2090
Mailing Address - Fax:805-547-2095
Practice Address - Street 1:628 CALIFORNIA BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2542
Practice Address - Country:US
Practice Address - Phone:805-547-2090
Practice Address - Fax:805-547-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3049777207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC3049777OtherCA STATE LICENSE
613177600OtherOWCP
CAZZZ50256YOtherBLUE SHIELD OF CALIFORNIA
W21609Medicare PIN
613177600OtherOWCP