MEDICARE: DR. CAROL VR DE COSTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	A183780	NY
2	208100000X	Physical Medicine & Rehabilitation Physician	183780	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902904626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL VR DE COSTA MD

Provider Business Mailing Address
First Line	:	142 JORALEMON ST
Second Line	:	SUITE 3A
City	:	BROOKLYN
State	:	NY
Zip	:	11201-4747
Country	:	US
Telephone Number	:	718-852-6949
Fax Number	:	718-852-7075

Provider Business Practice Location Address
First Line	:	142 JORALEMON ST
Second Line	:	SUITE 3A
City	:	BROOKLYN
State	:	NY
Zip	:	11201-4747
Country	:	US
Telephone Number	:	718-852-6949
Fax Number	:	718-852-7075

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	03/10/2015

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