Provider Demographics
NPI:1013959675
Name:HACKER, RICHARD KEITH (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:KEITH
Last Name:HACKER
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 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-253-8226
Mailing Address - Fax:570-253-8228
Practice Address - Street 1:412 COMO RD
Practice Address - Street 2:
Practice Address - City:LAKE COMO
Practice Address - State:PA
Practice Address - Zip Code:18437-1020
Practice Address - Country:US
Practice Address - Phone:570-798-2828
Practice Address - Fax:570-798-2636
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4287949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018670380007Medicaid
PA1018670380007Medicaid
PA100767JJMMedicare Oscar/Certification