Provider Demographics
NPI:1033257639
Name:KOENIG, JOHN EDWARD
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:KOENIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 N MAIN ST
Mailing Address - Street 2:P. O. BOX 143
Mailing Address - City:CLARION
Mailing Address - State:IA
Mailing Address - Zip Code:50525-1137
Mailing Address - Country:US
Mailing Address - Phone:515-532-2728
Mailing Address - Fax:515-532-2728
Practice Address - Street 1:609 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:IA
Practice Address - Zip Code:50525-1137
Practice Address - Country:US
Practice Address - Phone:515-532-2728
Practice Address - Fax:515-532-2728
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0725291Medicaid