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General NPI Number Information
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NPI Number | 1295978385
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Entity Type | Organization
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Legal Business Name | THEODORE A. DACOSTA MD PA
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Dates
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Enumeration Date | 04/20/2009
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Last Update Date | 04/20/2009
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Provider Practice Location Address
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Address Line | 22 CHESTNUT ST
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City | LIVINGSTON
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State | NJ
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Zip | 07039-5502
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Country | US
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Telephone | 973-422-0094
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Fax | 973-422-9895
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Provider Business Mailing Address
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Address Line | 22 CHESTNUT ST
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City | LIVINGSTON
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State | NJ
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Zip | 07039-5502
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Country | US
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Telephone | 973-422-0094
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Fax | 973-422-9895
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THEODORE ANTHONY DACOSTA
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Credential | MD
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Telephone | 973-422-0094
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | MA56002
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License Number State | NJ
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