Provider Demographics
NPI:1962091033
Name:COSTANZA MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:COSTANZA MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTANZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-667-4402
Mailing Address - Street 1:187 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-4320
Mailing Address - Country:US
Mailing Address - Phone:973-667-3719
Mailing Address - Fax:973-667-6974
Practice Address - Street 1:187 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-4320
Practice Address - Country:US
Practice Address - Phone:973-667-3719
Practice Address - Fax:973-667-6974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty