Healthcare Provider Details

I. General information

NPI: 1386728905
Provider Name (Legal Business Name): CAROL COSTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLYN COSTA

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N STATE ST
GREENFIELD IN
46140-1270
US

IV. Provider business mailing address

4685 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 317-468-4415
  • Fax:
Mailing address:
  • Phone: 317-802-6301
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01052652
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: