MEDICARE: DR. KENNETH L DISTEFANO SR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	25MA02454300	NJ

General Provider Information

NPI Number	:	1346324852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH L DISTEFANO SR. MD

Provider Business Mailing Address
First Line	:	1 MOUNT PROSPECT AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-2707
Country	:	US
Telephone Number	:	973-239-7777
Fax Number	:	973-239-7082

Provider Business Practice Location Address
First Line	:	1 MOUNT PROSPECT AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-2707
Country	:	US
Telephone Number	:	973-239-7777
Fax Number	:	973-239-7082

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	09/06/2023

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