Provider Demographics
NPI:1215924790
Name:KOROSHETZ, ANNE (MD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:KOROSHETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 ASPEN HILL ROAD
Mailing Address - Street 2:STE 200
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853
Mailing Address - Country:US
Mailing Address - Phone:301-438-5150
Mailing Address - Fax:301-460-0199
Practice Address - Street 1:10215 FERNWOOD RD
Practice Address - Street 2:SUITE 620
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1106
Practice Address - Country:US
Practice Address - Phone:301-530-6646
Practice Address - Fax:301-530-0773
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA519282085R0202X
MDD00666702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6190847Medicaid
MD413835000Medicaid
022886K90OtherMEDICARE
DC039290100Medicaid
A57214Medicare UPIN
022886K90Medicare PIN
MD413835000Medicaid