Individual
KELLY DISTEFANO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
619 RIVER DR, ELMWOOD PARK, NJ 07407-1317
(201) 703-2900
Mailing address
PO BOX 1849, LEWISTON, ME 04241-1849
(207) 784-2554
(207) 777-1439
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
MA08068600
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0114219
—
NJ
05
—
PENDING
—
NJ
Enumeration date
06/04/2006
Last updated
07/24/2018
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