{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "THEODORE A. DACOSTA MD PA",
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"FirstLineMailingAddress": "22 CHESTNUT ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LIVINGSTON",
"MailingAddressStateName": "NJ",
"MailingAddressPostalCode": "07039-5502",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "973-422-0094",
"MailingAddressFaxNumber": "973-422-9895",
"FirstLinePracticeLocationAddress": "22 CHESTNUT ST",
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"PracticeLocationAddressCityName": "LIVINGSTON",
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"PracticeLocationAddressFaxNumber": "973-422-9895",
"EnumerationDate": "04/20/2009",
"LastUpdateDate": "04/20/2009",
"NPIDeactivationReasonCode": null,
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"NPIReactivationDate": null,
"GenderCode": null,
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"AuthorizedOfficialLastName": "DACOSTA",
"AuthorizedOfficialFirstName": "THEODORE",
"AuthorizedOfficialMiddleName": "ANTHONY",
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"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "973-422-0094",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Gastroenterology Physician",
"LicenseNumber": "MA56002",
"LicenseNumberStateCode": "NJ",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}