Provider Demographics
NPI:1669400651
Name:COSTANZA, CARL (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:COSTANZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1939
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-1939
Mailing Address - Country:US
Mailing Address - Phone:973-743-2331
Mailing Address - Fax:973-743-1441
Practice Address - Street 1:187 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2311
Practice Address - Country:US
Practice Address - Phone:973-667-4402
Practice Address - Fax:973-667-6974
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA059660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0814788000OtherAMERIHEALTH
NJ6583709Medicaid
NJ6583709Medicaid
NJG11175Medicare UPIN