Provider Demographics
NPI:1942284591
Name:DECOSTE, SUSAN (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:DECOSTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:90 LIBBEY PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3129
Mailing Address - Country:US
Mailing Address - Phone:781-335-9700
Mailing Address - Fax:781-335-9709
Practice Address - Street 1:90 LIBBEY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3129
Practice Address - Country:US
Practice Address - Phone:781-335-9700
Practice Address - Fax:781-335-9709
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA71958207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070016618OtherRAILROAD MEDICARE
4292OtherHARVARD PILGRIM
724847OtherTUFTS
J09323OtherBC/BS
MA3063534Medicaid
MA3063534Medicaid
4292OtherHARVARD PILGRIM