Provider Demographics
NPI:1487021127
Name:BACHILLER, ALFRED KONOPKA (DO)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:KONOPKA
Last Name:BACHILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 SNYDER AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-3186
Mailing Address - Country:US
Mailing Address - Phone:570-903-0551
Mailing Address - Fax:
Practice Address - Street 1:1705 WARREN AVE, 303
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2665
Practice Address - Country:US
Practice Address - Phone:570-326-8500
Practice Address - Fax:570-326-8049
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS019620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty