Healthcare Provider Details

I. General information

NPI: 1649414301
Provider Name (Legal Business Name): MARK KOENEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2009
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 UNION ST SUITE 1704
SEATTLE WA
98101-2341
US

IV. Provider business mailing address

601 UNION ST SUITE 1704
SEATTLE WA
98101-2341
US

V. Phone/Fax

Practice location:
  • Phone: 206-623-1949
  • Fax:
Mailing address:
  • Phone: 206-623-1949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD00041348
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberA106795
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA106795
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberMD00041348
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: