Provider Demographics
NPI:1649396060
Name:COSTA, STEPHEN JOHN (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
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 1:22 ALBERT ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4102
Mailing Address - Country:US
Mailing Address - Phone:718-981-3575
Mailing Address - Fax:718-981-3574
Practice Address - Street 1:22 ALBERT ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4102
Practice Address - Country:US
Practice Address - Phone:718-981-3575
Practice Address - Fax:718-981-3574
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0C031111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
X0C031Medicare ID - Type Unspecified