Provider Demographics
NPI:1497961569
Name:COSTANZO, ALFRED S (DC)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:S
Last Name:COSTANZO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6614
Mailing Address - Country:US
Mailing Address - Phone:203-748-4800
Mailing Address - Fax:203-748-1239
Practice Address - Street 1:191 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6614
Practice Address - Country:US
Practice Address - Phone:203-748-4800
Practice Address - Fax:203-748-1239
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP463970OtherOXFORD
CT506594OtherAETNA
CT050000747CT02OtherANTHEM BLUE CROSS BLUE
CTT97981Medicare UPIN