1033368741 NPI number — LAURA NORTON PETROVICH MD PC

Table of content: (NPI 1033368741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033368741 NPI number — LAURA NORTON PETROVICH MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURA NORTON PETROVICH MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033368741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1224 10TH ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CORONADO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92118-3416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-435-2234
Provider Business Mailing Address Fax Number:
619-435-1784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1224 10TH ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92118-3416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-435-2234
Provider Business Practice Location Address Fax Number:
619-435-1784
Provider Enumeration Date:
09/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PETROVICH
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
NORTON
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
619-435-2234

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A72085 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A72085 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A720850 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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