MEDICARE: DR. KENNETH LOUIS DISTEFANO 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	207Q00000X	Family Medicine Physician	25MA08855100	NJ
2	207Q00000X	Family Medicine Physician	255630-1	NY

General Provider Information

NPI Number	:	1619146677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH LOUIS DISTEFANO 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	:	02/25/2008
Last Update Date	:	01/05/2011

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