Provider Demographics
NPI:1821314360
Name:KOENIG, JUSTIN JACOB (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JACOB
Last Name:KOENIG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 502
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601
Practice Address - Country:US
Practice Address - Phone:574-647-5875
Practice Address - Fax:574-647-5878
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005590A208600000X
IL036.136515208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300024549Medicaid