Provider Demographics
NPI:1619080611
Name:COSTA, MICHAEL JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:COSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11131 JOURNAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485
Mailing Address - Country:US
Mailing Address - Phone:540-625-2527
Mailing Address - Fax:540-709-7211
Practice Address - Street 1:11131 JOURNAL PARKWAY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485
Practice Address - Country:US
Practice Address - Phone:540-785-7810
Practice Address - Fax:540-786-3099
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619080611Medicaid
VA1619080611Medicaid