Provider Demographics
NPI:1033199369
Name:D'COSTA, MOLLY M (DO)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:M
Last Name:D'COSTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 N ELM ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3634
Mailing Address - Country:US
Mailing Address - Phone:630-856-6820
Mailing Address - Fax:630-856-6810
Practice Address - Street 1:2710 111TH STREET
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565-1189
Practice Address - Country:US
Practice Address - Phone:630-355-9531
Practice Address - Fax:630-355-9532
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3463207Q00000X
IL036116813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2271700Medicaid
IA1271700Medicaid
IA3271700Medicaid
IA4271700Medicaid
IA3271700Medicaid
IAH81102Medicare UPIN