Provider Demographics
NPI:1235711086
Name:KOENIG, GAVIN
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:KOENIG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13657 W MCDOWELL RD STE 220
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2603
Mailing Address - Country:US
Mailing Address - Phone:623-848-5609
Mailing Address - Fax:
Practice Address - Street 1:13657 W MCDOWELL RD STE 220
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2603
Practice Address - Country:US
Practice Address - Phone:623-848-5609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61519536207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine