Provider Demographics
NPI:1659442317
Name:STOVER, LAURIE BERNARD (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:BERNARD
Last Name:STOVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:ANNE
Other - Last Name:BERNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-5841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71978208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A719780Medicaid
CAH65754Medicare UPIN