Provider Demographics
NPI:1891800116
Name:PETROVICH, LAURA NORTON (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:NORTON
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:NORTON
Other - Last Name:FAGERLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1224 10TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3416
Mailing Address - Country:US
Mailing Address - Phone:619-435-2234
Mailing Address - Fax:619-435-1784
Practice Address - Street 1:1224 10TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3416
Practice Address - Country:US
Practice Address - Phone:619-435-2234
Practice Address - Fax:619-435-1784
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72085208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA72085OtherMEDICARE NORIDIAN
CA00A720850Medicaid
CAA72085OtherMEDICARE NORIDIAN