=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114199163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTOPHER COSTANZO M D INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2008
-----------------------------------------------------
Last Update Date | 07/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2190 LYNN RD SUITE 380
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-373-9919
-----------------------------------------------------
Fax | 805-379-3495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2190 LYNN RD SUITE 380
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-373-9919
-----------------------------------------------------
Fax | 805-379-3495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHRISTOPHER COSTANZO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-373-9919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2082S0105X
-----------------------------------------------------
Taxonomy Name | Surgery of the Hand (Plastic Surgery) Physician
-----------------------------------------------------
License Number | G46454
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------