Provider Demographics
NPI:1134201874
Name:KOERNER, ROGER S (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:S
Last Name:KOERNER
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 1:210 JUPITER LAKES BLVD
Mailing Address - Street 2:SUITE 106, BLDG 3000
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7191
Mailing Address - Country:US
Mailing Address - Phone:561-401-9082
Mailing Address - Fax:561-401-9251
Practice Address - Street 1:210 JUPITER LAKES BLVD
Practice Address - Street 2:SUITE 106, BLDG 3000
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7191
Practice Address - Country:US
Practice Address - Phone:561-401-9082
Practice Address - Fax:561-401-9251
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0032452207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99485OtherBC/BS GROUP PROVIDER NUM
FL50860OtherBC/BS INDIV PROVIDER NUM
FL99485OtherBC/BS GROUP PROVIDER NUM
FL50860ZMedicare ID - Type Unspecified