MEDICARE: ALLEN MICHAEL BLACKBURN COSTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	0101289286	VA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1740690924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLEN MICHAEL BLACKBURN COSTA MD

Provider Business Mailing Address
First Line	:	EMORY UNIVERSITY HOSPITAL
Second Line	:	1364 CLIFTON RD. NE
City	:	ATLANTA
State	:	GA
Zip	:	30332-1064
Country	:	US
Telephone Number	:	404-712-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	EMORY UNIVERSITY HOSPITAL
Second Line	:	1364 CLIFTON RD. NE
City	:	ATLANTA
State	:	GA
Zip	:	30332-1064
Country	:	US
Telephone Number	:	404-712-2000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	05/06/2026

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