Provider Demographics
NPI:1619146677
Name:DISTEFANO, KENNETH LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LOUIS
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2707
Mailing Address - Country:US
Mailing Address - Phone:973-239-7777
Mailing Address - Fax:973-239-7082
Practice Address - Street 1:1 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2707
Practice Address - Country:US
Practice Address - Phone:973-239-7777
Practice Address - Fax:973-239-7082
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08855100207Q00000X
NY255630-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine