Healthcare Provider Details

I. General information

NPI: 1750305975
Provider Name (Legal Business Name): JANE O'GREEN KOENIG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CADILLAC DR SUITE# 130
SACRAMENTO CA
95825-5453
US

IV. Provider business mailing address

77 CADILLAC DR SUITE# 130
SACRAMENTO CA
95825-5453
US

V. Phone/Fax

Practice location:
  • Phone: 916-929-8564
  • Fax: 916-929-4529
Mailing address:
  • Phone: 916-929-8564
  • Fax: 916-929-4529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG38095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: