Provider Demographics
NPI:1124000781
Name:KOENIG, CLINT JEREMY (MD)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:JEREMY
Last Name:KOENIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5450 FRANTZ RD STE 360
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4141
Mailing Address - Country:US
Mailing Address - Phone:614-533-6497
Mailing Address - Fax:614-544-6370
Practice Address - Street 1:697 THOMAS LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3931
Practice Address - Country:US
Practice Address - Phone:614-566-5414
Practice Address - Fax:614-533-0433
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY246840-1207Q00000X
OH35085021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG89563Medicare UPIN
NYJ400005340Medicare PIN