=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902033236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTORIA CHRISTINA COSTALES MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2009
-----------------------------------------------------
Last Update Date | 12/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 718 TEANECK RD
-----------------------------------------------------
City | TEANECK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07666-4245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-541-5929
-----------------------------------------------------
Fax | 201-379-5611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 UNIVERSITY PLZ STE 205
-----------------------------------------------------
City | HACKENSACK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07601-6208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 052259
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 25MA12007800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------