Provider Demographics
NPI:1215025424
Name:COSTA, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 W LANE AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-3538
Mailing Address - Country:US
Mailing Address - Phone:614-457-4827
Mailing Address - Fax:614-457-4832
Practice Address - Street 1:1315 W LANE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3538
Practice Address - Country:US
Practice Address - Phone:614-457-4827
Practice Address - Fax:614-457-4832
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069599207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2053530Medicaid
OH2586296OtherGROUP MEDICAID
OH201308320030OtherCARESOURCE
OH4125142OtherMEDICARE PTAN
OH4125142OtherMEDICARE PTAN
OHCO0854614Medicare PIN