Provider Demographics
NPI:1598834335
Name:DIANE LH COLTRIN, MD PC
Entity Type:Organization
Organization Name:DIANE LH COLTRIN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:LH
Authorized Official - Last Name:COLTRIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-227-8675
Mailing Address - Street 1:6315 N CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4006
Mailing Address - Country:US
Mailing Address - Phone:757-227-8675
Mailing Address - Fax:757-461-1452
Practice Address - Street 1:6315 N CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4006
Practice Address - Country:US
Practice Address - Phone:757-227-8675
Practice Address - Fax:757-461-1452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050603174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6207588Medicaid
F84211Medicare UPIN
VA160001267Medicare ID - Type Unspecified