Provider Demographics
NPI:1932311149
Name:COSTA JR, DANIEL JESSE (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JESSE
Last Name:COSTA JR
Suffix:
Gender:M
Credentials:DC
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 592
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60566-0592
Mailing Address - Country:US
Mailing Address - Phone:630-717-8900
Mailing Address - Fax:
Practice Address - Street 1:4315 AZALEA DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1181
Practice Address - Country:US
Practice Address - Phone:630-717-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBLUECROSSBLUE SHIELDOtherGROUP # 02221920