Provider Demographics
NPI:1851396386
Name:KOENIG, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622-0270
Mailing Address - Country:US
Mailing Address - Phone:208-462-3533
Mailing Address - Fax:208-462-3736
Practice Address - Street 1:856 BANKS LOWMAN RD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83622-8102
Practice Address - Country:US
Practice Address - Phone:208-462-3533
Practice Address - Fax:208-462-3736
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010140515OtherBS
ID85795OtherBC
ID806406200Medicaid
ID85795OtherBC
ID1106187Medicare ID - Type Unspecified
ID806406200Medicaid
IDH59372Medicare UPIN