Basic Information
| Provider Information | |||||||||
| NPI: | 1295773729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORTUM | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037669737 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 JOSEPH SIEWICK DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039229501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | TEP4621 | NE | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 0101240278 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 484645 | 01 | VA | NCPPO | OTHER | 033579 | 01 | VA | ANTHEM | OTHER | 1295773729 | 05 | VA | MEDICAID | K142-0001 | 01 | VA | CARE FIRST 2005 | OTHER | 9445356 | 01 | VA | PHCS | OTHER |