Healthcare Provider Details

I. General information

NPI: 1801897608
Provider Name (Legal Business Name): KENNETH A WIDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 N MAIN ST
HARRISONBURG VA
22802-4632
US

IV. Provider business mailing address

6040 PUBLIC LANDING ROAD
SNOW HILL MD
21863
US

V. Phone/Fax

Practice location:
  • Phone: 540-434-1941
  • Fax: 540-433-8277
Mailing address:
  • Phone: 410-632-1100
  • Fax: 410-632-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101041002
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101041002
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: