Provider Demographics
NPI:1285742700
Name:DESTEFANO, ROBERT K (ATC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:K
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:553 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-6067
Mailing Address - Country:US
Mailing Address - Phone:732-506-6491
Mailing Address - Fax:732-914-2474
Practice Address - Street 1:711 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-7716
Practice Address - Country:US
Practice Address - Phone:734-349-8801
Practice Address - Fax:732-914-2474
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer