Provider Demographics
NPI:1891734265
Name:KOENKER, RALPH MAXIMILLIAN (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:MAXIMILLIAN
Last Name:KOENKER
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 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:415-883-8082
Practice Address - Street 1:180 ROWLAND WAY
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5009
Practice Address - Country:US
Practice Address - Phone:415-290-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG609812085R0202X, 2085R0204X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G609810Medicaid
CA300121787OtherRAILROAD MEDICARE
CA00G609810OtherBLUE SHIELD
CA300035771OtherRAILROAD MEDICARE
CA300121787OtherRAILROAD MEDICARE
CABZ376XMedicare PIN
CABZ376YMedicare PIN
CA00G609815Medicare PIN
CAE27201Medicare UPIN
CA00G609810Medicaid
CA00G609814Medicare PIN
CA00G609810OtherBLUE SHIELD
CABZ376TMedicare PIN
CABZ376WMedicare PIN