Provider Demographics
NPI:1356397202
Name:KOERNER, THEODORE AW JR (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:AW
Last Name:KOERNER
Suffix:JR
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 2551
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52244-2551
Mailing Address - Country:US
Mailing Address - Phone:319-688-9045
Mailing Address - Fax:
Practice Address - Street 1:23 PENFRO DR STE 2
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246
Practice Address - Country:US
Practice Address - Phone:319-330-7667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10952083X0100X
IA25617207Q00000X
IAMD-256172083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A03097Medicare UPIN