Provider Demographics
NPI:1033368741
Name:LAURA NORTON PETROVICH MD PC
Entity Type:Organization
Organization Name:LAURA NORTON PETROVICH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:NORTON
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-435-2234
Mailing Address - Street 1:1224 10TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3416
Mailing Address - Country:US
Mailing Address - Phone:619-435-2234
Mailing Address - Fax:619-435-1784
Practice Address - Street 1:1224 10TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3416
Practice Address - Country:US
Practice Address - Phone:619-435-2234
Practice Address - Fax:619-435-1784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72085207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A720850Medicaid
CAH72026Medicare UPIN
CA00A720850Medicaid