1669400651 NPI number — DR. CARL COSTANZA M.D.

Table of content: DR. CARL COSTANZA M.D. (NPI 1669400651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669400651 NPI number — DR. CARL COSTANZA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTANZA
Provider First Name:
CARL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1669400651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1939
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07003-1939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-743-2331
Provider Business Mailing Address Fax Number:
973-743-1441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
187 CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NUTLEY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07110-2311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-667-4402
Provider Business Practice Location Address Fax Number:
973-667-6974
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MA059660 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0814788000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 6583709 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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