Provider Demographics
NPI:1689661951
Name:ROFFE, KENNETH A (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:ROFFE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 LAFAYETTE RD
Mailing Address - Street 2:STE 300
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-4411
Mailing Address - Country:US
Mailing Address - Phone:973-940-0423
Mailing Address - Fax:973-940-0399
Practice Address - Street 1:225 ROUTE 23 NORTH
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NJ
Practice Address - Zip Code:07419
Practice Address - Country:US
Practice Address - Phone:973-209-1550
Practice Address - Fax:973-209-4832
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06073300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6177808Medicaid
NJR0181004Medicare ID - Type Unspecified
NJ6177808Medicaid