Provider Demographics
NPI:1689978926
Name:COSTA, JOHN LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
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 1:3 GINO'S WAY
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877
Mailing Address - Country:US
Mailing Address - Phone:203-244-5500
Mailing Address - Fax:
Practice Address - Street 1:3 GINOS WAY
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4441
Practice Address - Country:US
Practice Address - Phone:203-244-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105040208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics