Healthcare Provider Details

I. General information

NPI: 1114914181
Provider Name (Legal Business Name): JOSEPH A COSTA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MILL RD
FAIRHAVEN MA
02719-5208
US

IV. Provider business mailing address

200 MILL RD STE 180
FAIRHAVEN MA
02719-5255
US

V. Phone/Fax

Practice location:
  • Phone: 508-758-3781
  • Fax: 508-758-4455
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45334
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: