Provider Demographics
NPI:1538112164
Name:KOENIGSBERG, MARLON R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARLON
Middle Name:R
Last Name:KOENIGSBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 GOODELL STREET
Mailing Address - Street 2:STE. 240
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1243
Mailing Address - Country:US
Mailing Address - Phone:716-645-9694
Mailing Address - Fax:716-845-6699
Practice Address - Street 1:850 HOPKINS ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-1729
Practice Address - Country:US
Practice Address - Phone:716-688-9641
Practice Address - Fax:716-688-9645
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008415103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00930589Medicaid
NY00930589Medicaid
NY14238JMedicare ID - Type Unspecified