Provider Demographics
NPI:1437309549
Name:COSTA, JEROME F
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:F
Last Name:COSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEROME
Other - Middle Name:FRANCIS
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:M D
Mailing Address - Street 1:5301 BRANSFORD DR
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1123
Mailing Address - Country:US
Mailing Address - Phone:714-994-3757
Mailing Address - Fax:
Practice Address - Street 1:5301 BRANSFORD DR
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1123
Practice Address - Country:US
Practice Address - Phone:714-994-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA323462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry