Provider Demographics
NPI:1477634814
Name:COSTA, LOURDES MARIA (OD)
Entity type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:MARIA
Last Name:COSTA
Suffix:
Gender:F
Credentials:OD
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 920593
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77292-0593
Mailing Address - Country:US
Mailing Address - Phone:713-884-8114
Mailing Address - Fax:
Practice Address - Street 1:4412 NORTH FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-3606
Practice Address - Country:US
Practice Address - Phone:713-884-8114
Practice Address - Fax:713-699-0191
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2015-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5202T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX917354OtherBLOCK VISION
TXPO81175E5Medicaid
TX919239OtherEYEMED
TXU74906Medicare UPIN
TX919239OtherEYEMED