Provider Demographics
NPI:1508811670
Name:LAINE, FRED J (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:LAINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12005 VALLEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1020
Mailing Address - Country:US
Mailing Address - Phone:804-364-0690
Mailing Address - Fax:
Practice Address - Street 1:2602 BUFORD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-3422
Practice Address - Country:US
Practice Address - Phone:804-272-8806
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7212160Medicaid
E09186Medicare UPIN