Provider Demographics
NPI:1255768057
Name:CENTRAL COAST MEDICAL GROUP
Entity type:Organization
Organization Name:CENTRAL COAST MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SAWYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-740-9400
Mailing Address - Street 1:119 S B ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6903
Mailing Address - Country:US
Mailing Address - Phone:805-740-9400
Mailing Address - Fax:805-741-2640
Practice Address - Street 1:119 S B ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6903
Practice Address - Country:US
Practice Address - Phone:805-740-9400
Practice Address - Fax:805-741-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750395224OtherNPI
CA1427062942OtherNPI
CA1689688442OtherNPI