Provider Demographics
NPI:1205977204
Name:KORETZKY, MARTIN BRUCE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:BRUCE
Last Name:KORETZKY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6513 GARDENWICK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2537
Mailing Address - Country:US
Mailing Address - Phone:410-823-3626
Mailing Address - Fax:
Practice Address - Street 1:10751 FALLS RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4517
Practice Address - Country:US
Practice Address - Phone:410-823-3626
Practice Address - Fax:410-296-5018
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1741103TA0400X, 103TC0700X, 103TF0000X, 103TH0100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG455MBMedicare ID - Type Unspecified