Provider Demographics
NPI:1972808335
Name:JACK M. COSTA, M.D., P.C.
Entity Type:Organization
Organization Name:JACK M. COSTA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:M
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-391-2516
Mailing Address - Street 1:3650 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1710
Mailing Address - Country:US
Mailing Address - Phone:703-391-2516
Mailing Address - Fax:703-476-8244
Practice Address - Street 1:3650 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1710
Practice Address - Country:US
Practice Address - Phone:703-391-2516
Practice Address - Fax:703-476-8244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-17
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028288174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9320OtherBLUE CROSS BLUE SHIELD
VA003539OtherANTHEM
C62572Medicare UPIN
VA003539OtherANTHEM