Provider Demographics
NPI:1184655482
Name:COSTA, MARC LANCE (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:LANCE
Last Name:COSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9008
Mailing Address - Country:US
Mailing Address - Phone:304-933-3850
Mailing Address - Fax:304-933-3859
Practice Address - Street 1:527 MEDICAL PARK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9008
Practice Address - Country:US
Practice Address - Phone:304-933-3850
Practice Address - Fax:304-933-3859
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD060675L174400000X
WV19442208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000000140320OtherUNISON THREE RIVERS
PA048032003OtherCIGNA
PAG78377OtherHEALTH AMERICA
PAG78377OtherHEALTH ASSURANCE
PA1461312OtherBLUE CROSS BLUE SHIELD
PA1531290OtherGATEWAY
PA0019436000001Medicaid
PA3133024OtherAETNA
PAG78377OtherADVANTRA MEDICARE
PA319922OtherUPMC MEDICARE
PAG78377OtherHEALTH AMERICA
PAG78377Medicare UPIN