Healthcare Provider Details

I. General information

NPI: 1639754740
Provider Name (Legal Business Name): GILLIAN COSTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAG 1 1640 TOMCAT BLVD STE 100
VIRGINIA BEACH VA
23460-2227
US

IV. Provider business mailing address

1640 TOMCAT BLVD STE 100
VIRGINIA BEACH VA
23460-2227
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-3933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101276109
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: