Healthcare Provider Details

I. General information

NPI: 1154300739
Provider Name (Legal Business Name): DAMIAN P DICOSTANZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MIDLAND AVE
PORT CHESTER NY
10573-4943
US

IV. Provider business mailing address

14275 MIDWAY RD SUITE 400
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 800-942-3376
  • Fax: 914-934-9819
Mailing address:
  • Phone: 214-932-8029
  • Fax: 610-271-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number168313
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number168313
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: