Provider Demographics
NPI:1578616058
Name:COSTA, LAWRENCE WILLIAM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:WILLIAM
Last Name:COSTA
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:MONTEAGLE
Mailing Address - State:TN
Mailing Address - Zip Code:37356-0009
Mailing Address - Country:US
Mailing Address - Phone:931-924-4200
Mailing Address - Fax:931-924-4202
Practice Address - Street 1:21 1ST ST.
Practice Address - Street 2:
Practice Address - City:MONTEAGLE
Practice Address - State:TN
Practice Address - Zip Code:37356-0009
Practice Address - Country:US
Practice Address - Phone:931-924-4200
Practice Address - Fax:931-924-4202
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000018125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN917201OtherHERITAGE JOHN DEERE
TN3722428Medicaid
TN688779OtherBLUE CROSS PREFERRED
TN4536007OtherFEDERAL BLACK LUNG
TN917201OtherHERITAGE JOHN DEERE
TN4536007OtherFEDERAL BLACK LUNG