Provider Demographics
NPI:1366409898
Name:SAN LUIS OBISPO EYE ASSOCIATES, A MEDICAL GROUP INC
Entity type:Organization
Organization Name:SAN LUIS OBISPO EYE ASSOCIATES, A MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-434-5970
Mailing Address - Street 1:234 HEATHER CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-8765
Mailing Address - Country:US
Mailing Address - Phone:805-434-5970
Mailing Address - Fax:805-434-5973
Practice Address - Street 1:234 HEATHER CT
Practice Address - Street 2:SUITE 102
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-8765
Practice Address - Country:US
Practice Address - Phone:805-434-5970
Practice Address - Fax:805-434-5973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068240Medicaid
CAGR0068240Medicaid
CA1159330002Medicare NSC
CAW13658Medicare ID - Type Unspecified
CAW13658AMedicare PIN