Provider Demographics
NPI:1558429464
Name:COSTA, JOSEPH (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 ALUM ROCK AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-2463
Mailing Address - Country:US
Mailing Address - Phone:408-258-7512
Mailing Address - Fax:408-258-6963
Practice Address - Street 1:4600 ALUM ROCK AVE STE 4
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-2463
Practice Address - Country:US
Practice Address - Phone:408-258-7512
Practice Address - Fax:408-258-6963
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8952T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089521Medicaid
CASD0089521Medicaid