Provider Demographics
NPI:1972821601
Name:TAIT, LAUREN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:MARIE
Last Name:TAIT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 E CHURCH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5909
Mailing Address - Country:US
Mailing Address - Phone:805-925-2529
Mailing Address - Fax:
Practice Address - Street 1:100 CASA ST
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1883
Practice Address - Country:US
Practice Address - Phone:805-925-2529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1218502085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA161399Medicare PIN
CACB238301Medicare PIN
CACB238300Medicare PIN