Provider Demographics
NPI:1447516711
Name:CENTRAL COAST MEDICAL ONCOLOGY CORP
Entity type:Organization
Organization Name:CENTRAL COAST MEDICAL ONCOLOGY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DICHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-349-9393
Mailing Address - Street 1:1325 E CHURCH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5915
Mailing Address - Country:US
Mailing Address - Phone:805-925-2529
Mailing Address - Fax:805-496-2861
Practice Address - Street 1:1325 E CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5915
Practice Address - Country:US
Practice Address - Phone:805-925-2529
Practice Address - Fax:805-496-2861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54341207RH0003X
CAG718862085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18159Medicare PIN