Provider Demographics
NPI:1992702682
Name:DURRWACHTER, KENNETH ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:DURRWACHTER
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 1:1705 WARREN AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2665
Mailing Address - Country:US
Mailing Address - Phone:570-601-6230
Mailing Address - Fax:570-601-6232
Practice Address - Street 1:1705 WARREN AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2647
Practice Address - Country:US
Practice Address - Phone:570-601-6230
Practice Address - Fax:570-601-6232
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045039L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1147510OtherCIGNA
PA5664476OtherAETNA
PA721386OtherHIGHMARK BLUE SHIELD
PA1279162OtherUNITEDHEALTHCARE
PA7420OtherGEISINGER HEALTH PLAN
PA0012837330009Medicaid
PA002787OtherFIRST PRIORITY HEALTH
PAF26620OtherHEALTHAMERICA
PA721386OtherHIGHMARK BLUE SHIELD
F26620Medicare UPIN
PA721386Medicare PIN