Provider Demographics
NPI:1184697765
Name:KORNIENKO, WALTER (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:KORNIENKO
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 1:207 N BROAD ST
Mailing Address - Street 2:3RD FLR.
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:484-386-6300
Mailing Address - Fax:484-380-3178
Practice Address - Street 1:760 W SPROUL RD STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-4005
Practice Address - Country:US
Practice Address - Phone:484-386-6300
Practice Address - Fax:484-380-3178
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038297E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001101410Medicaid
PA81895GT6Medicare PIN