Provider Demographics
NPI:1982693511
Name:COSTA, RICHARD C (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
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 1:40 LAKE CTR
Mailing Address - Street 2:401 ROUTE 73 NORTH SUITE 201A
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3425
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0346
Practice Address - Street 1:339 N ROUTE 73
Practice Address - Street 2:SUITE 1
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-9707
Practice Address - Country:US
Practice Address - Phone:856-767-8228
Practice Address - Fax:856-753-7836
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMB48420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2098601Medicaid
NJC52638Medicare UPIN
NJ2098601Medicaid