Healthcare Provider Details

I. General information

NPI: 1740817808
Provider Name (Legal Business Name): LAURA M STODDARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA CLINE

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10620 PARK RD STE 202
CHARLOTTE NC
28210-0106
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 704-468-0089
  • Fax:
Mailing address:
  • Phone: 262-641-8400
  • Fax: 262-784-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number75907
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: