Healthcare Provider Details

I. General information

NPI: 1417918301
Provider Name (Legal Business Name): KENNETH J. LORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ROBBY DR
LEESPORT PA
19533-9435
US

IV. Provider business mailing address

111 ROBBY DR
LEESPORT PA
19533-9435
US

V. Phone/Fax

Practice location:
  • Phone: 610-223-8885
  • Fax:
Mailing address:
  • Phone: 610-223-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD025549E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: