Provider Demographics
NPI:1295773729
Name:KORTUM, LAUREL DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:DIANE
Last Name:KORTUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-766-9737
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:STE 202
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1756
Practice Address - Country:US
Practice Address - Phone:703-922-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NETEP4621207L00000X
VA0101240278207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA484645OtherNCPPO
VA033579OtherANTHEM
VA1295773729Medicaid
VAK142-0001OtherCARE FIRST 2005
VA9445356OtherPHCS
VAI65740Medicare UPIN
VA1295773729Medicaid
DC020367F89Medicare PIN