Healthcare Provider Details

I. General information

NPI: 1104074707
Provider Name (Legal Business Name): ALLYSON REGINE SELF-STOICO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALLYSON REGINE SELF

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE STE 415
PASADENA CA
91105-3154
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-8440
  • Fax: 626-449-8999
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA08463800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA108876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: