Provider Demographics
NPI:1962479055
Name:LATTIMORE, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:LATTIMORE
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 1:185 FALLBROOK ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-0514
Mailing Address - Country:US
Mailing Address - Phone:570-282-1732
Mailing Address - Fax:570-282-6529
Practice Address - Street 1:LAKE PLAZA 2 ROUTE 706 E
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:PA
Practice Address - Zip Code:18801-0285
Practice Address - Country:US
Practice Address - Phone:570-278-3393
Practice Address - Fax:570-278-1716
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035251E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
148096Medicare ID - Type Unspecified
B39825Medicare UPIN