Provider Demographics
NPI:1043816812
Name:COSTABELLA, RICARDO
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:COSTABELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75210-1350
Mailing Address - Country:US
Mailing Address - Phone:214-865-3070
Mailing Address - Fax:
Practice Address - Street 1:4500 SPRING AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75210-1350
Practice Address - Country:US
Practice Address - Phone:214-865-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10124172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker