Provider Demographics
NPI:1215245154
Name:KENNETH T. DEFUSCO M.D. PA
Entity type:Organization
Organization Name:KENNETH T. DEFUSCO M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEFUSCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-994-1544
Mailing Address - Street 1:2 W NORTHFIELD ROAD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07936
Mailing Address - Country:US
Mailing Address - Phone:973-994-1544
Mailing Address - Fax:973-994-2387
Practice Address - Street 1:2 W NORTHFIELD ROAD
Practice Address - Street 2:SUITE 206
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07936
Practice Address - Country:US
Practice Address - Phone:973-994-1544
Practice Address - Fax:973-994-2387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA23958207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC59770Medicare UPIN