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General NPI Number Information
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NPI Number | 1932217171
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Entity Type | Individual
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Provider Name | JONATHAN LEEDS COSTA MD
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Gender | Male
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 08/03/2015
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Provider Practice Location Address
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Address Line | 3 TORREY PINES WAY
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City | BRENTWOOD
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State | TN
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Zip | 37027-8945
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Country | US
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Telephone | 814-882-8936
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Fax |
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Provider Business Mailing Address
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Address Line | 3 TORREY PINES WAY
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City | BRENTWOOD
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State | TN
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Zip | 37027-8945
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | MD061822L
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License Number State | PA
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