Basic Information
| Provider Information | |||||||||
| NPI: | 1467584409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CENTENO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1206 | ||||||||
| Address2: | |||||||||
| City: | GOLETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931161206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059643383 | ||||||||
| FaxNumber: | 8056833400 | ||||||||
| Practice Location | |||||||||
| Address1: | 316 S STRATFORD AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053483700 | ||||||||
| FaxNumber: | 8056833400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A64528 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A645280 | 05 | CA | MEDICAID |