Provider Demographics
NPI:1326197021
Name:KISCH DUPONT, AGNES M (MD)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:M
Last Name:KISCH DUPONT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 COKESBURY RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08801-2046
Mailing Address - Country:US
Mailing Address - Phone:908-638-4920
Mailing Address - Fax:
Practice Address - Street 1:59 KOCH AVE
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-4400
Practice Address - Country:US
Practice Address - Phone:973-538-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA052497002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ717799C2EOtherMEDICARE BILLING NO.
NJKI717799Medicare ID - Type Unspecified
NJF23391Medicare UPIN