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Individual

DR. LAUREL DIANE KORTUM

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
M.D.

Contact information

Practice address
3620 JOSEPH SIEWICK DR, STE 202, FAIRFAX, VA 22033-1756
(703) 922-9501
Mailing address
3998 FAIR RIDGE DR, STE 300, FAIRFAX, VA 22033-2921
(703) 766-9737
(703) 766-9725

Taxonomy

Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
TEP4621
NE
207LP2900X
Pain Medicine (Anesthesiology) Physician
Primary
0101240278
VA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
033579
ANTHEM
VA
05
1295773729
VA
01
484645
NCPPO
VA
01
9445356
PHCS
VA
01
K142-0001
CARE FIRST 2005
VA
Enumeration date
06/04/2006
Last updated
03/05/2015
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