Provider Demographics
NPI:1598981540
Name:COSTA, PHILIP ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ANTHONY
Last Name:COSTA
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 1:15 GREENBROOK RD
Mailing Address - Street 2:P.O.BOX 972
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812-2629
Mailing Address - Country:US
Mailing Address - Phone:732-968-1111
Mailing Address - Fax:732-968-2055
Practice Address - Street 1:15 GREENBROOK RD
Practice Address - Street 2:
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812-2629
Practice Address - Country:US
Practice Address - Phone:732-968-1111
Practice Address - Fax:732-968-2055
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00584900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084996Medicare ID - Type Unspecified