Provider Demographics
NPI:1790779148
Name:DEFUSCO, KENNETH T (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:T
Last Name:DEFUSCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W NORTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-3789
Mailing Address - Country:US
Mailing Address - Phone:973-994-1544
Mailing Address - Fax:973-994-2387
Practice Address - Street 1:2 W NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-3789
Practice Address - Country:US
Practice Address - Phone:973-994-1544
Practice Address - Fax:973-994-2387
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA23958207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1508407Medicaid
DE460902Medicare PIN
C59770Medicare UPIN