Provider Demographics
NPI:1770517724
Name:CENTRAL COAST PEDIATRICS INC
Entity type:Organization
Organization Name:CENTRAL COAST PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-549-0888
Mailing Address - Street 1:1235 OSOS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3600
Mailing Address - Country:US
Mailing Address - Phone:805-549-0888
Mailing Address - Fax:805-549-8463
Practice Address - Street 1:1235 OSOS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3600
Practice Address - Country:US
Practice Address - Phone:805-549-0888
Practice Address - Fax:805-549-8463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059300Medicaid
CAW1309Medicare PIN