Healthcare Provider Details

I. General information

NPI: 1487021127
Provider Name (Legal Business Name): ALFRED KONOPKA BACHILLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 WARREN AVE, 303
WILLIAMSPORT PA
17701-2665
US

IV. Provider business mailing address

1264 SNYDER AVE
SCRANTON PA
18504-3186
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-8500
  • Fax: 570-326-8049
Mailing address:
  • Phone: 570-903-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS019620
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: