Provider Demographics
NPI:1013056647
Name:COSTA, ROGER A (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
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 1:165 W END AVE
Mailing Address - Street 2:SUITE # 1F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5503
Mailing Address - Country:US
Mailing Address - Phone:212-724-1929
Mailing Address - Fax:
Practice Address - Street 1:165 W END AVE
Practice Address - Street 2:SUITE # 1F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5503
Practice Address - Country:US
Practice Address - Phone:212-724-1929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC03900-0111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX22691Medicare ID - Type Unspecified