Provider Demographics
NPI:1801897608
Name:WIDRA, KENNETH A (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:WIDRA
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 1:6040 PUBLIC LANDING ROAD
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21863
Mailing Address - Country:US
Mailing Address - Phone:410-632-1100
Mailing Address - Fax:410-632-2476
Practice Address - Street 1:1241 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22802-4632
Practice Address - Country:US
Practice Address - Phone:540-434-1941
Practice Address - Fax:540-433-8277
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010410022084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA084255OtherSENTARA OPTIMA
VA258840OtherANTHEM
VA004945166Medicaid
VA216331000OtherMAGELLAN
VAA164832OtherVALUE OPTIONS
VA004945166Medicaid
E22989Medicare UPIN