Provider Demographics
NPI:1265586093
Name:COSTA, TIMOTHY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:COSTA
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 1:801 E WILLIAMS AVE STE 2210
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-3052
Mailing Address - Country:US
Mailing Address - Phone:775-867-7740
Mailing Address - Fax:775-423-4219
Practice Address - Street 1:801 E WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-3052
Practice Address - Country:US
Practice Address - Phone:775-867-7740
Practice Address - Fax:775-423-4219
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6380851-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00379498OtherMEDICARE RR
UTDB3302OtherMEDICARE RR GROUP
UT$$$$$$$$$001Medicaid
UTP00379498OtherMEDICARE RR
UTDB3302OtherMEDICARE RR GROUP
UT000069025Medicare PIN