Provider Demographics
NPI:1750305975
Name:KOENIG, JANE O'GREEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:O'GREEN
Last Name:KOENIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 CADILLAC DR
Mailing Address - Street 2:SUITE# 130
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-5453
Mailing Address - Country:US
Mailing Address - Phone:916-929-8564
Mailing Address - Fax:916-929-4529
Practice Address - Street 1:77 CADILLAC DR
Practice Address - Street 2:SUITE# 130
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-5453
Practice Address - Country:US
Practice Address - Phone:916-929-8564
Practice Address - Fax:916-929-4529
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38095174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0015060Medicaid
A89653Medicare UPIN
CAGR0015060Medicaid