1114199163 NPI number — CHRISTOPHER COSTANZO M D INC

Table of content: (NPI 1114199163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114199163 NPI number — CHRISTOPHER COSTANZO M D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTOPHER COSTANZO M D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114199163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2190 LYNN RD
Provider Second Line Business Mailing Address:
SUITE 380
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91360-1980
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-373-9919
Provider Business Mailing Address Fax Number:
805-379-3495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2190 LYNN RD
Provider Second Line Business Practice Location Address:
SUITE 380
Provider Business Practice Location Address City Name:
THOUSAND OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91360-1980
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-373-9919
Provider Business Practice Location Address Fax Number:
805-379-3495
Provider Enumeration Date:
03/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COSTANZO
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-373-9919

Provider Taxonomy Codes

  • Taxonomy code: 2082S0105X , with the licence number:  G46454 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G46454 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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