Provider Demographics
NPI:1114199163
Name:CHRISTOPHER COSTANZO M D INC
Entity Type:Organization
Organization Name:CHRISTOPHER COSTANZO M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTANZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-373-9919
Mailing Address - Street 1:2190 LYNN RD
Mailing Address - Street 2:SUITE 380
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1980
Mailing Address - Country:US
Mailing Address - Phone:805-373-9919
Mailing Address - Fax:805-379-3495
Practice Address - Street 1:2190 LYNN RD
Practice Address - Street 2:SUITE 380
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1980
Practice Address - Country:US
Practice Address - Phone:805-373-9919
Practice Address - Fax:805-379-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG464542082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG46454OtherMEDICAL LICENSE
CAG46454OtherMEDICAL LICENSE