Provider Demographics
NPI:1780971317
Name:DISCEPOLA, KIRSTEN (DPM)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:DISCEPOLA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:
Other - Last Name:BARISONEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1500 PLEASANT VALLEY WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2956
Mailing Address - Country:US
Mailing Address - Phone:973-731-1266
Mailing Address - Fax:973-731-1712
Practice Address - Street 1:1500 PLEASANT VALLEY WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2956
Practice Address - Country:US
Practice Address - Phone:973-731-1266
Practice Address - Fax:973-731-1712
Is Sole Proprietor?:No
Enumeration Date:2011-07-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY65 P80778213E00000X
NJ25MD00322300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0451363Medicaid
NJ36840YXSEMedicare PIN