Provider Demographics
NPI:1053589077
Name:CENTRAL COAST INSTITUTE FOR PLASTIC SURGERY, AMC
Entity type:Organization
Organization Name:CENTRAL COAST INSTITUTE FOR PLASTIC SURGERY, AMC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DONATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-544-6000
Mailing Address - Street 1:1531 HIGUERA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2917
Mailing Address - Country:US
Mailing Address - Phone:805-544-6000
Mailing Address - Fax:805-544-5460
Practice Address - Street 1:1531 HIGUERA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2917
Practice Address - Country:US
Practice Address - Phone:805-544-6000
Practice Address - Fax:805-544-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50869261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF49778Medicare UPIN
CAA50869Medicare PIN