Provider Demographics
NPI:1942204656
Name:KOENIG, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:1120 N 103RD PLZ
Practice Address - Street 2:SUITE 102
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1114
Practice Address - Country:US
Practice Address - Phone:402-354-0120
Practice Address - Fax:402-354-0125
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17844207R00000X, 207K00000X, 207RP1001X, 207RS0012X
IA23943207K00000X, 207R00000X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026480109Medicaid
IA1942204656Medicaid
NE099099304Medicare PIN
NE265214KOMedicare ID - Type Unspecified
IA290006070OtherRAILROAD MEDICARE
IA1973925Medicaid