Healthcare Provider Details

I. General information

NPI: 1285633362
Provider Name (Legal Business Name): JOHN J. COSTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 COHASSET AVE UNIT #2
BUZZARDS BAY MA
02532-3270
US

IV. Provider business mailing address

33 COHASSET AVE UNIT #2
BUZZARDS BAY MA
02532-3270
US

V. Phone/Fax

Practice location:
  • Phone: 508-759-7555
  • Fax: 508-759-7355
Mailing address:
  • Phone: 508-759-7555
  • Fax: 508-759-7355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number00000
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: