Provider Demographics
NPI:1629411855
Name:COSTA, PETER ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ANTHONY
Last Name:COSTA
Suffix:
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 1:5 BEAVER POND CT
Mailing Address - Street 2:
Mailing Address - City:STONY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10980-3518
Mailing Address - Country:US
Mailing Address - Phone:845-729-7297
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-2403
Practice Address - Country:US
Practice Address - Phone:336-713-4500
Practice Address - Fax:336-713-4501
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2019-003982080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program