Healthcare Provider Details

I. General information

NPI: 1891800116
Provider Name (Legal Business Name): LAURA NORTON PETROVICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA NORTON FAGERLUND M.D.

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 10TH ST SUITE 200
CORONADO CA
92118-3416
US

IV. Provider business mailing address

1224 10TH ST SUITE 200
CORONADO CA
92118-3416
US

V. Phone/Fax

Practice location:
  • Phone: 619-435-2234
  • Fax: 619-435-1784
Mailing address:
  • Phone: 619-435-2234
  • Fax: 619-435-1784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA72085
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA72085
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: