Provider Demographics
NPI:1356353478
Name:ALPHA, KENNETH W (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:ALPHA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 MIFFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503
Mailing Address - Country:US
Mailing Address - Phone:570-342-3145
Mailing Address - Fax:570-344-1309
Practice Address - Street 1:1850 S TOWNSHIP BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640
Practice Address - Country:US
Practice Address - Phone:570-654-1641
Practice Address - Fax:570-654-2835
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000865152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410024725OtherRAILROAD MEDICARE
PA001240520Medicaid
AL513333OtherHIGH MARK BLUE SHIELD
20987OtherGEISINGER HEALTH PLAN
072343OtherFIRST PRIORITY HEALTH
506554OtherAETNA
506554OtherAETNA
PA001240520Medicaid