Healthcare Provider Details

I. General information

NPI: 1013056647
Provider Name (Legal Business Name): ROGER A COSTA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 W END AVE SUITE # 1F
NEW YORK NY
10023-5503
US

IV. Provider business mailing address

165 W END AVE SUITE # 1F
NEW YORK NY
10023-5503
US

V. Phone/Fax

Practice location:
  • Phone: 212-724-1929
  • Fax:
Mailing address:
  • Phone: 212-724-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberC03900-0
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: