Provider Demographics
NPI:1801997267
Name:COSTA, ROBERT KENNETH JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KENNETH
Last Name:COSTA
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:4063 POPLAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715
Mailing Address - Country:US
Mailing Address - Phone:413-237-0107
Mailing Address - Fax:
Practice Address - Street 1:1550 FAULK ST STE 2100
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5087
Practice Address - Country:US
Practice Address - Phone:704-289-2553
Practice Address - Fax:704-289-6496
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA156629207V00000X
SC86997207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3181430Medicaid
MAG69738Medicare UPIN
MACOA23799Medicare ID - Type Unspecified