=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750915450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANA LUIZA FONTES DE AZEVEDO COSTA M.D., PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2020
-----------------------------------------------------
Last Update Date | 07/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 CENTENNIAL DR
-----------------------------------------------------
City | PEABODY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01960-7938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-216-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 CENTENNIAL DR
-----------------------------------------------------
City | PEABODY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01960-7938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-216-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0110X
-----------------------------------------------------
Taxonomy Name | Pediatric Ophthalmology and Strabismus Specialist Physician Physician
-----------------------------------------------------
License Number | 2022010573
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207WX0110X
-----------------------------------------------------
Taxonomy Name | Pediatric Ophthalmology and Strabismus Specialist Physician Physician
-----------------------------------------------------
License Number | 1020205
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------