Provider Demographics
NPI:1437169810
Name:COSTA, ANGELA FAHEY (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:FAHEY
Last Name:COSTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:138 E REYNOLDS RD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-1257
Mailing Address - Country:US
Mailing Address - Phone:859-273-2020
Mailing Address - Fax:859-272-8089
Practice Address - Street 1:138 E REYNOLDS RD
Practice Address - Street 2:SUITE #101
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-1257
Practice Address - Country:US
Practice Address - Phone:859-273-2020
Practice Address - Fax:859-272-8089
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1661DT152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT002576OtherGEORGIA LICENSE
KY1661DTOtherSTATE LICENSURE