Healthcare Provider Details

I. General information

NPI: 1316097066
Provider Name (Legal Business Name): STEPHEN COSTIGLIOLA P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E 70TH ST
NEW YORK NY
10021-4823
US

IV. Provider business mailing address

PO BOX 29234
NEW YORK NY
10087-9234
US

V. Phone/Fax

Practice location:
  • Phone: 646-797-8305
  • Fax: 646-797-8515
Mailing address:
  • Phone: 631-329-6925
  • Fax: 631-329-6951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009525
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: