Basic Information
| Provider Information | |||||||||
| NPI: | 1891734265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOENKER | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | MAXIMILLIAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843418 | ||||||||
| FaxNumber: | 4158838082 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 ROWLAND WAY | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949455009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152901500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G60981 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | G60981 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085N0700X | G60981 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 00G609810 | 05 | CA | MEDICAID | 300121787 | 01 | CA | RAILROAD MEDICARE | OTHER | 00G609810 | 01 | CA | BLUE SHIELD | OTHER | 300035771 | 01 | CA | RAILROAD MEDICARE | OTHER |