Provider Demographics
NPI:1588669832
Name:COSTA, CHRISTOPHER P (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:P
Last Name:COSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1910 CUSTOMER CARE WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5167
Mailing Address - Country:US
Mailing Address - Phone:209-384-6488
Mailing Address - Fax:855-202-9336
Practice Address - Street 1:821 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635
Practice Address - Country:US
Practice Address - Phone:209-826-1045
Practice Address - Fax:209-826-0952
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2018-08-17
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
NE20028207Q00000X
CAG82066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025207400Medicaid
NE4705330312Medicaid
NE4705330312Medicaid
NEG25250Medicare UPIN
NE10025207400Medicaid