Healthcare Provider Details

I. General information

NPI: 1043325632
Provider Name (Legal Business Name): WALTER GREGORY KORYTOWSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NONE NONE NONE M.D.

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SPRING ARBOR RD SUITE 400
JACKSON MI
49203-8605
US

IV. Provider business mailing address

3333 SPRING ARBOR RD SUITE 400
JACKSON MI
49203-8605
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-6435
  • Fax: 517-783-6347
Mailing address:
  • Phone: 517-783-6435
  • Fax: 517-783-6347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301040841
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: