Provider Demographics
NPI:1841348166
Name:LAURITZEN, DEREK BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:BRIAN
Last Name:LAURITZEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2905
Mailing Address - Country:US
Mailing Address - Phone:805-544-0006
Mailing Address - Fax:
Practice Address - Street 1:941 CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-434-2350
Practice Address - Fax:805-434-9888
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77319207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7808216OtherAETNA PIN
CA00G773190Medicaid
CAG77319OtherBLUE CROSS
CA00G773190OtherBLUE SHIELD OF CALIFORNIA
P00470195Medicare PIN
CA00G773190OtherBLUE SHIELD OF CALIFORNIA
WG77319FMedicare PIN