Provider Demographics
NPI:1023097524
Name:DECOSTA, NEAL THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:NEAL
Middle Name:THOMAS
Last Name:DECOSTA
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 1:501 GLADES RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1419
Mailing Address - Country:US
Mailing Address - Phone:561-939-5500
Mailing Address - Fax:
Practice Address - Street 1:520 S ELM AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-3845
Practice Address - Country:US
Practice Address - Phone:314-962-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104301207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206819716Medicaid
MO018010681Medicare ID - Type Unspecified
MO206819716Medicaid