Provider Demographics
NPI:1942345020
Name:DESTEFANO, ROBERT L (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 GARIBALDI AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-3709
Mailing Address - Country:US
Mailing Address - Phone:973-777-9040
Mailing Address - Fax:973-777-5262
Practice Address - Street 1:361 GARIBALDI AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-3709
Practice Address - Country:US
Practice Address - Phone:973-777-9040
Practice Address - Fax:973-777-5262
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00336400111NS0005X
NYX010312-1111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ456477Medicare ID - Type Unspecified
NJT45529Medicare UPIN