Provider Demographics
NPI:1164245072
Name:GAZA, VICTOR MICHAEL COSCOLLUELA (PT, DPT)
Entity type:Individual
Prefix:
First Name:VICTOR MICHAEL
Middle Name:COSCOLLUELA
Last Name:GAZA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08835-1622
Mailing Address - Country:US
Mailing Address - Phone:862-224-2034
Mailing Address - Fax:
Practice Address - Street 1:304 W 117TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1573
Practice Address - Country:US
Practice Address - Phone:917-493-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02290100225100000X
NY052248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist