Provider Demographics
NPI:1306009410
Name:MARTIN KOENIGSBERG D.O. PA.
Entity Type:Organization
Organization Name:MARTIN KOENIGSBERG D.O. PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOENIGSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-556-5744
Mailing Address - Street 1:19-03 MAPLE AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1553
Mailing Address - Country:US
Mailing Address - Phone:973-556-5744
Mailing Address - Fax:201-818-4863
Practice Address - Street 1:19-03 MAPLE AVE
Practice Address - Street 2:STE2
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1553
Practice Address - Country:US
Practice Address - Phone:973-556-5744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03362200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0061638Medicaid