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General NPI Number Information
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NPI Number | 1629154091
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Entity Type | Individual
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Provider Name | DR. MARK --- COSTANZA
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Gender | Male
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Dates
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Enumeration Date | 10/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1900 RIDGE RD HEALTHWORKS-WNY, LLP
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City | WEST SENECA
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State | NY
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Zip | 14224-3332
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Country | US
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Telephone | 716-712-0670
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Fax | 716-712-0674
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Provider Business Mailing Address
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Address Line | 1900 RIDGE RD HEALTHWORKS-WNY, LLP
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City | WEST SENECA
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State | NY
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Zip | 14224-3332
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Country | US
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Telephone | 716-712-0670
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Fax | 716-712-0674
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083X0100X
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Taxonomy Name | Occupational Medicine Physician
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License Number | 168031
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License Number State | NY
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