Healthcare Provider Details

I. General information

NPI: 1740690924
Provider Name (Legal Business Name): ALLEN MICHAEL BLACKBURN COSTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N WASHINGTON ST
ALEXANDRIA VA
22314-2311
US

IV. Provider business mailing address

2661 RIVA RD STE 1030
ANNAPOLIS MD
21401-7131
US

V. Phone/Fax

Practice location:
  • Phone: 703-548-5588
  • Fax: 703-549-1599
Mailing address:
  • Phone: 667-354-5528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101289286
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: