Provider Demographics
NPI:1710984232
Name:KOROTKI, LEO ISRAEL (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:ISRAEL
Last Name:KOROTKI
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 1:1205 YORK RD
Mailing Address - Street 2:SUITE 22
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6210
Mailing Address - Country:US
Mailing Address - Phone:410-823-9333
Mailing Address - Fax:410-823-9335
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:SUITE 22
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-823-9333
Practice Address - Fax:410-823-9335
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2016-02-17
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MDD00240172081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218835OtherMAMSI/ALLIANCE
MDS042OtherBLUE CHOICE/BC/BS FEDERAL
MD5037OtherBC/BS
MD218835OtherMAMSI/ALLIANCE
MD5037Medicare PIN