Provider Demographics
NPI:1417918301
Name:LORD, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:LORD
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 1:111 ROBBY DR
Mailing Address - Street 2:
Mailing Address - City:LEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:19533-9435
Mailing Address - Country:US
Mailing Address - Phone:610-223-8885
Mailing Address - Fax:
Practice Address - Street 1:111 ROBBY DR
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-9435
Practice Address - Country:US
Practice Address - Phone:610-223-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025549E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000905187Medicaid
PA000905187Medicaid
B41092Medicare UPIN