Provider Demographics
NPI:1104074707
Name:SELF-STOICO, ALLYSON REGINE (MD)
Entity type:Individual
Prefix:
First Name:ALLYSON
Middle Name:REGINE
Last Name:SELF-STOICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:REGINE
Other - Last Name:SELF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 FAIRMOUNT AVE STE 415
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3154
Practice Address - Country:US
Practice Address - Phone:626-449-8440
Practice Address - Fax:626-449-8999
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08463800208000000X
CAA108876208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics