Provider Demographics
NPI:1245225366
Name:KOERNER, THEODORE G (DO)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:G
Last Name:KOERNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-0877
Mailing Address - Country:US
Mailing Address - Phone:856-227-7048
Mailing Address - Fax:
Practice Address - Street 1:4911 BLACK HORSE PIKE (RT 42)
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-1730
Practice Address - Country:US
Practice Address - Phone:856-227-7048
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB031874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0073996001OtherAMERIHEALTH NJ
5433019OtherAETNA
NJ2191105Medicaid
E06053Medicare UPIN
NJ0073996001OtherAMERIHEALTH NJ