Provider Demographics
NPI:1689620627
Name:DECOSTA, BRIAN RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:RICHARD
Last Name:DECOSTA
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:PO BOX 11686
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0128
Mailing Address - Country:US
Mailing Address - Phone:731-300-0352
Mailing Address - Fax:901-753-2896
Practice Address - Street 1:367 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2080
Practice Address - Country:US
Practice Address - Phone:731-300-0352
Practice Address - Fax:901-753-2896
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN366022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3877720Medicare ID - Type Unspecified
TNH72242Medicare UPIN