Provider Demographics
NPI:1255301388
Name:KOENIG, GREGORY S (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:KOENIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:415 US HIGHWAY 95A S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FERNLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89408-9007
Mailing Address - Country:US
Mailing Address - Phone:775-575-1966
Mailing Address - Fax:775-575-1967
Practice Address - Street 1:415 US HIGHWAY 95A S
Practice Address - Street 2:SUITE 101
Practice Address - City:FERNLEY
Practice Address - State:NV
Practice Address - Zip Code:89408-9007
Practice Address - Country:US
Practice Address - Phone:775-575-1966
Practice Address - Fax:775-575-1967
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV321152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002501100Medicaid
NVU63264Medicare UPIN
NV4117010001Medicare NSC
NV002501100Medicaid