MEDICARE: DR. MARK EDWARD 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	207R00000X	Internal Medicine Physician	54772	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	054772	OTHER	MA	TUFTS HEALTH PLAN
2	J10005	OTHER	MA	BCBS MA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912997420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDWARD COSTA MD

Provider Business Mailing Address
First Line	:	361 WOODWARD ST
Second Line	:
City	:	WABAN
State	:	MA
Zip	:	02468-2027
Country	:	US
Telephone Number	:	617-777-4080
Fax Number	:	617-224-4306

Provider Business Practice Location Address
First Line	:	361 WOODWARD ST
Second Line	:
City	:	WABAN
State	:	MA
Zip	:	02468-2027
Country	:	US
Telephone Number	:	617-777-4080
Fax Number	:	617-224-4306

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

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	08/27/2009

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Directions to “ DR. MARK EDWARD COSTA MD” Practice Location

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