Provider Demographics
NPI:1881684652
Name:KOENIG, CARRIE JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:JEAN
Last Name:KOENIG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:JEAN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1128 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-3014
Mailing Address - Country:US
Mailing Address - Phone:515-239-4460
Mailing Address - Fax:515-239-4437
Practice Address - Street 1:1128 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-3014
Practice Address - Country:US
Practice Address - Phone:515-239-4460
Practice Address - Fax:515-956-4145
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002178152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0215749Medicaid
IAU81400Medicare UPIN
IAI21713Medicare PIN