Provider Demographics
NPI:1558395673
Name:DACOSTA, THEODORE A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:A
Last Name:DACOSTA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 S JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050
Mailing Address - Country:US
Mailing Address - Phone:973-674-8866
Mailing Address - Fax:973-672-9299
Practice Address - Street 1:85 S JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050
Practice Address - Country:US
Practice Address - Phone:973-674-8866
Practice Address - Fax:973-672-9299
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05600200207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6881106Medicaid
G23990Medicare UPIN
NJ6881106Medicaid