Kenneth Louis Distefano, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

25MA08855100 Issued in NJ

Practice address

1 Mount Prospect Ave
Verona, NJ 07044-2707

Phone

(973) 239-7777

Fax

(973) 239-7082

NPI assigned

Feb 25, 2008

Last updated

Jan 5, 2011By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

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, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• 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": "1203897600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1294185600000",
    "number": "1619146677",
    "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": "LOUIS",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-02-25",
        "last_updated": "2011-01-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NJ",
            "license": "25MA08855100",
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NY",
            "license": "255630-1",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Danielle Joanna Desantis, PAC
• Sara Devito, MA, CCC-SLP
• Roger Philip Diruggiero, MD
• Discovery Mental Health LLC
• Kenneth L Distefano Sr., MD
• Bradley T Doolen, O.D.
• Ashlee Lynn Dorreman, MA, LAC
• Jaime Doshi, LPC
• Simone Alicia Douge, MD
• Kimberly Drinkwater, DO

• Family Medicine Physician in Verona, NJ
• Providers in Verona, NJ by specialty
• Family Medicine Physician in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 2011; 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.