Provider Demographics
NPI:1255312211
Name:KOROSHETZ, WALTER JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JOSEPH
Last Name:KOROSHETZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:VBK 915
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-7413
Practice Address - Fax:617-726-2353
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50968207R00000X, 207RN0300X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Not Answered2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ05512OtherBCBS MA
MA050968OtherTUFTS HEALTH PLAN
MA3014916Medicaid
MAJ05512OtherBCBS MA
MAJ05512Medicare ID - Type Unspecified