Provider Demographics
NPI:1750348520
Name:ADESSA, KENNETH JOHN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:ADESSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-5285
Mailing Address - Country:US
Mailing Address - Phone:973-768-8105
Mailing Address - Fax:973-827-7413
Practice Address - Street 1:3699 ROUTE 46
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-1049
Practice Address - Country:US
Practice Address - Phone:973-768-8105
Practice Address - Fax:973-827-7413
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06454200207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7780508Medicaid
NJ011741X5MMedicare PIN
G78435Medicare UPIN