Provider Demographics
NPI:1396961470
Name:KOENIG, KENNETH S (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
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 491836
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-1836
Mailing Address - Country:US
Mailing Address - Phone:530-246-1139
Mailing Address - Fax:530-246-9958
Practice Address - Street 1:8935 OLNEY PARK DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-9717
Practice Address - Country:US
Practice Address - Phone:530-246-1139
Practice Address - Fax:530-246-9958
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63182208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G631820Medicaid
CA00G631820Medicaid
00G631820Medicare ID - Type Unspecified