Provider Demographics
NPI:1588841969
Name:KOENIG, MARK DIETER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DIETER
Last Name:KOENIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W. ARBOR DR.
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:619-543-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96822207P00000X
TXN3118207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1588841969OtherTRICARE SOUTH
TX206084001Medicaid
TX8CA490OtherBCBSTX
TX8L14223Medicare PIN
TX8CA490OtherBCBSTX