Provider Demographics
NPI:1902458565
Name:KORTSCHAK, MICHAEL (RD, LD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:KORTSCHAK
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MAGONA TRL
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-7236
Mailing Address - Country:US
Mailing Address - Phone:512-270-8741
Mailing Address - Fax:
Practice Address - Street 1:105 MAGONA TRL
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-7236
Practice Address - Country:US
Practice Address - Phone:512-270-8741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85698133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered