Kenneth L Distefano Sr., MD

Primary specialty

Plastic Surgery PhysicianTaxonomy code 208200000X

License

25MA02454300 Issued in NJ

Practice address

1 Mount Prospect Ave
Verona, NJ 07044-2707

Phone

(973) 239-7777

Fax

(973) 239-7082

NPI assigned

Oct 24, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Champey Pain Group

  • Specialist
  • Verona, NJ
  • NPI 1992967103
  NPD (past)
• Robert J Agresti DO PA

  • Surgery of the Hand (Plastic Surgery) Physician
  • Verona, NJ
  • NPI 1962576025
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161648000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1693958400000",
    "number": "1346324852",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 MOUNT PROSPECT AVE",
            "city": "VERONA",
            "state": "NJ",
            "postal_code": "070442707",
            "telephone_number": "973-239-7777",
            "fax_number": "973-239-7082"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 MOUNT PROSPECT AVE",
            "city": "VERONA",
            "state": "NJ",
            "postal_code": "070442707",
            "telephone_number": "973-239-7777",
            "fax_number": "973-239-7082"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DISTEFANO",
        "first_name": "KENNETH",
        "middle_name": "L",
        "name_prefix": "Dr.",
        "name_suffix": "Sr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-10-24",
        "last_updated": "2023-09-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208200000X",
            "taxonomy_group": "",
            "desc": "Plastic Surgery",
            "state": "NJ",
            "license": "25MA02454300",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Benedict Dephillips, RPH
• Joelle Frances Dere, LCSW
• Danielle Joanna Desantis, PAC
• Sara Devito, MA, CCC-SLP
• Roger Philip Diruggiero, MD
• Kenneth Louis Distefano, MD
• Bradley T Doolen, O.D.
• Ashlee Lynn Dorreman, MA, LAC
• Jaime Doshi, LPC
• Simone Alicia Douge, MD

• Plastic Surgery Physician in Verona, NJ
• Providers in Verona, NJ by specialty
• Plastic Surgery Physician in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 6, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.