Provider Demographics
NPI:1811017221
Name:COSTA, NELI (RDO)
Entity Type:Individual
Prefix:MRS
First Name:NELI
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 ASHLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-2403
Mailing Address - Country:US
Mailing Address - Phone:508-995-6000
Mailing Address - Fax:508-995-7067
Practice Address - Street 1:846 ASHLEY BLVD
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745-2403
Practice Address - Country:US
Practice Address - Phone:508-995-6000
Practice Address - Fax:508-995-7067
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5945156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0708755Medicaid
MA5467500001Medicare ID - Type UnspecifiedMC