Retina Specialists of the Central Coast Inc

Primary specialty

Ophthalmology PhysicianTaxonomy code 207W00000X

License

C3049777 Issued in CA

Legal business name

RETINA SPECIALISTS OF THE CENTRAL COAST INC

Practice address

628 California Blvd
Suite C
San Luis Obispo, CA 93401-2542

Phone

(805) 547-2090

Fax

(805) 547-2095

NPI assigned

Dec 7, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Derek B. Lauritzen, M.D.

Title

President

Phone

(805) 547-2090

Specialties & licenses 1

Addresses

Other identifiers 3

Locations

Networks

• BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1258502400000",
    "number": "1821271248",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "628 CALIFORNIA BLVD",
            "address_2": "SUITE C",
            "city": "SAN LUIS OBISPO",
            "state": "CA",
            "postal_code": "934012542",
            "telephone_number": "805-547-2090",
            "fax_number": "805-547-2095"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "628 CALIFORNIA BLVD",
            "address_2": "SUITE C",
            "city": "SAN LUIS OBISPO",
            "state": "CA",
            "postal_code": "934012542",
            "telephone_number": "805-547-2090",
            "fax_number": "805-547-2095"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RETINA SPECIALISTS OF THE CENTRAL COAST INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-07",
        "last_updated": "2009-11-18",
        "status": "A",
        "authorized_official_last_name": "LAURITZEN",
        "authorized_official_first_name": "DEREK",
        "authorized_official_middle_name": "B.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "805-547-2090",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": "CA",
            "license": "C3049777",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CA STATE LICENSE",
            "identifier": "C3049777",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OWCP",
            "identifier": "613177600",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD OF CALIFORNIA",
            "identifier": "ZZZ50256Y",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Ophthalmology Physician in San Luis Obispo, CA
• Providers in San Luis Obispo, CA by specialty
• Ophthalmology Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.