Provider Demographics
NPI:1093211211
Name:KORYTKOWSKI, BONNIE ANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:ANNE
Last Name:KORYTKOWSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W3124 VAN ROY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W3124 VAN ROY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-3929
Practice Address - Country:US
Practice Address - Phone:920-730-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2021-09-23
Deactivation Date:2021-06-29
Deactivation Code:
Reactivation Date:2021-07-15
Provider Licenses
StateLicense IDTaxonomies
WI72653-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400769234Medicaid