Healthcare Provider Details

I. General information

NPI: 1649407347
Provider Name (Legal Business Name): CHRISTOPHER R COSTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 SEVEN HILLS DR STE 101
HENDERSON NV
89052
US

IV. Provider business mailing address

870 SEVEN HILLS DR STE 101
HENDERSON NV
89052-4378
US

V. Phone/Fax

Practice location:
  • Phone: 725-600-4477
  • Fax: 725-600-9191
Mailing address:
  • Phone: 725-600-4477
  • Fax: 725-600-9191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10044391
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD71549
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number241160
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number17614
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: