Healthcare Provider Details

I. General information

NPI: 1407261522
Provider Name (Legal Business Name): ANNA-MARIA ALICIA DE COSTA MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA-MARIA A CLARK

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 BECKNER RD
SANTA FE NM
87507-3774
US

IV. Provider business mailing address

1008 MINNEQUA AVE
PUEBLO CO
81004-3733
US

V. Phone/Fax

Practice location:
  • Phone: 505-477-2200
  • Fax:
Mailing address:
  • Phone: 719-557-5460
  • Fax: 719-557-4648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL36893
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberDR.0061777
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD2024-0260
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number66208-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: