Provider Demographics
NPI:1912997420
Name:COSTA, MARK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
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 1:361 WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-2027
Mailing Address - Country:US
Mailing Address - Phone:617-777-4080
Mailing Address - Fax:617-224-4306
Practice Address - Street 1:361 WOODWARD ST
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-2027
Practice Address - Country:US
Practice Address - Phone:617-777-4080
Practice Address - Fax:617-224-4306
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA054772OtherTUFTS HEALTH PLAN
MAJ10005OtherBCBS MA
MA3131874Medicaid
MAJ10005OtherBCBS MA
E56600Medicare UPIN