Provider Demographics
NPI:1407261522
Name:DE COSTA, ANNA-MARIA ALICIA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ANNA-MARIA
Middle Name:ALICIA
Last Name:DE COSTA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:ANNA-MARIA
Other - Middle Name:A
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1008 MINNEQUA AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3733
Mailing Address - Country:US
Mailing Address - Phone:719-557-5460
Mailing Address - Fax:719-557-4648
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-557-5460
Practice Address - Fax:719-557-4648
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66208-202085R0001X
SCLL36893208600000X
CODR.00617772085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000173787Medicaid