Basic Information
| Provider Information | |||||||||
| NPI: | 1629037171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARKIN | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TELLER | ||||||||
| OtherFirstName: | LAURIE | ||||||||
| OtherMiddleName: | SUSAN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5645 STONE RD | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032662442 | ||||||||
| FaxNumber: | 7032667158 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 STONE RD | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032662442 | ||||||||
| FaxNumber: | 7032667158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 04/16/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101053965 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0181539 | 01 | VA | UNITED HEALTHCARE | OTHER | 5615712 | 05 | VA | MEDICAID | 80940004 | 01 | VA | CAREFIRST | OTHER | 502653 | 01 | VA | NCPPO | OTHER | 288721 | 01 | VA | MAMSI | OTHER | 5565205 | 01 | VA | AETNA | OTHER | 383307 | 01 | VA | BCBS ANTHEM | OTHER | 746938 | 01 | VA | ONE HEALTH PLAN | OTHER |