Provider Demographics
NPI:1700114378
Name:COSTA, JUSTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 TANEY AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-5126
Mailing Address - Country:US
Mailing Address - Phone:301-662-0133
Mailing Address - Fax:
Practice Address - Street 1:1475 TANEY AVE STE 201
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-5126
Practice Address - Country:US
Practice Address - Phone:301-662-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202786208000000X
MDH0082753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics