Healthcare Provider Details

I. General information

NPI: 1962620419
Provider Name (Legal Business Name): VICTOR JOSEPH COSTA C.PED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2856 18TH ST S
HOMEWOOD AL
35209-2510
US

IV. Provider business mailing address

1127 30TH ST S
BIRMINGHAM AL
35205-1103
US

V. Phone/Fax

Practice location:
  • Phone: 205-879-2329
  • Fax:
Mailing address:
  • Phone: 205-354-3634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCPED2448
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: