Provider Demographics
NPI:1134125651
Name:COSTA, HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7812 GATEWAY BLVD E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-1803
Mailing Address - Country:US
Mailing Address - Phone:915-592-6868
Mailing Address - Fax:915-592-6889
Practice Address - Street 1:10555 VISTA DEL SOL DR
Practice Address - Street 2:STE 120
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7942
Practice Address - Country:US
Practice Address - Phone:915-592-6868
Practice Address - Fax:915-592-6889
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK0009207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116754606Medicaid
00W602OtherMEDICARE PROVIDER GROUP
DF4091OtherRAILROAD MEDICARE
DF4091OtherRAILROAD MEDICARE
TX8F3147Medicare PIN