Provider Demographics
NPI:1942305677
Name:KOENEKE, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:KOENEKE
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 1458
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1458
Mailing Address - Country:US
Mailing Address - Phone:316-262-4467
Mailing Address - Fax:316-262-0706
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:SUITE E-110
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-537-2651
Practice Address - Fax:785-537-4276
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23779207R00000X
KS0433608207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200606100CMedicaid
KS110217025Medicare PIN
KS200606100CMedicaid