Healthcare Provider Details

I. General information

NPI: 1770542771
Provider Name (Legal Business Name): DAVID DA COSTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD WP 3 NICU
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD WP 3 NICU
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-3146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number4301080608
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: