Healthcare Provider Details

I. General information

NPI: 1710984232
Provider Name (Legal Business Name): LEO ISRAEL KOROTKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

1205 YORK RD SUITE 22
LUTHERVILLE MD
21093-6210
US

IV. Provider business mailing address

1205 YORK RD SUITE 22
LUTHERVILLE MD
21093-6210
US

V. Phone/Fax

Practice location:
  • Phone: 410-823-9333
  • Fax: 410-823-9335
Mailing address:
  • Phone: 410-823-9333
  • Fax: 410-823-9335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberD0024017
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: