Provider Demographics
NPI:1700977923
Name:COSTANZO, ERIC (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:COSTANZO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 HIGHWAY 70 STE 6A
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-2610
Mailing Address - Country:US
Mailing Address - Phone:732-528-5900
Mailing Address - Fax:732-528-0887
Practice Address - Street 1:2640 HIGHWAY 70 STE 6A
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-2610
Practice Address - Country:US
Practice Address - Phone:732-528-5900
Practice Address - Fax:732-528-0887
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07782000207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0138461Medicaid
NJ0138461Medicaid