Provider Demographics
NPI:1629122650
Name:DICOSTANZO, VINCENT JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:JOHN
Last Name:DICOSTANZO
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 1:450 WESTERN HIGHWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962
Mailing Address - Country:US
Mailing Address - Phone:845-359-1303
Mailing Address - Fax:845-359-1457
Practice Address - Street 1:450 WESTERN HIGHWAY
Practice Address - Street 2:SUITE C
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962
Practice Address - Country:US
Practice Address - Phone:845-359-1303
Practice Address - Fax:845-359-1457
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2720111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor