Provider Demographics
NPI:1598963845
Name:COSTA, ROBERT O (LMT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:O
Last Name:COSTA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CAMINO LINDA
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-8041
Mailing Address - Country:US
Mailing Address - Phone:505-417-6182
Mailing Address - Fax:
Practice Address - Street 1:19 CAMINO LINDA
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-8041
Practice Address - Country:US
Practice Address - Phone:505-417-6182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-09
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5365225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist