Provider Demographics
NPI:1245812106
Name:KOEBE, SAMUEL DAVID (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DAVID
Last Name:KOEBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29624 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1296
Mailing Address - Country:US
Mailing Address - Phone:608-756-6278
Mailing Address - Fax:
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI817592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology