Provider Demographics
NPI:1487966636
Name:KOENIGSBERGER, CAROL ANN (MD, PHD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:KOENIGSBERGER
Suffix:
Gender:F
Credentials:MD, PHD
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 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:619-464-1165
Mailing Address - Fax:619-567-1011
Practice Address - Street 1:8950 VILLA LA JOLLA DR STE B223
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1715
Practice Address - Country:US
Practice Address - Phone:858-658-0655
Practice Address - Fax:877-991-6138
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-03
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1144002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA114400OtherMEDICAL BOARD OF CALIFORNIA
IDM-16713OtherIDAHO STATE BOARD OF MEDICINE