Provider Demographics
NPI:1609253806
Name:KOENIG, MIKAELA JEAN
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:JEAN
Last Name:KOENIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:JEAN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:513 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-9675
Mailing Address - Country:US
Mailing Address - Phone:605-384-3418
Mailing Address - Fax:
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3418
Practice Address - Fax:605-384-5240
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine