Provider Demographics
NPI:1043325632
Name:KORYTOWSKY, WALTER GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:GREGORY
Last Name:KORYTOWSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3333 SPRING ARBOR RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-8605
Mailing Address - Country:US
Mailing Address - Phone:517-783-6435
Mailing Address - Fax:517-783-6347
Practice Address - Street 1:3333 SPRING ARBOR RD
Practice Address - Street 2:SUITE 400
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-8605
Practice Address - Country:US
Practice Address - Phone:517-783-6435
Practice Address - Fax:517-783-6347
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040841207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0703800982OtherBLUE CROSS BLUE SHIELD MI
MIP58275OtherBLUE CHOICE/CARE NETWORK
MI0320049OtherPHP MICHIGAN
MI1570689Medicaid
MA4301040841OtherMEDICAL LICENSE NUMBER
MI0703800982OtherBLUE CROSS BLUE SHIELD MI
MI03800984072Medicare ID - Type Unspecified