MEDICARE: DR. WILLIAM FREDERICK KORTUM III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	027100	LA

General Provider Information

NPI Number	:	1225156151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM FREDERICK KORTUM III MD

Provider Business Mailing Address
First Line	:	3414 MOSS ST STE A
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70507-6107
Country	:	US
Telephone Number	:	337-235-1212
Fax Number	:

Provider Business Practice Location Address
First Line	:	3414 MOSS ST STE A
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70507-6107
Country	:	US
Telephone Number	:	337-235-1212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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