Basic Information
| Provider Information | |||||||||
| NPI: | 1588669832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 CUSTOMER CARE WAY | ||||||||
| Address2: | |||||||||
| City: | ATWATER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953015167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093846488 | ||||||||
| FaxNumber: | 8552029336 | ||||||||
| Practice Location | |||||||||
| Address1: | 821 TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | LOS BANOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098261045 | ||||||||
| FaxNumber: | 2098260952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/17/2006 | ||||||||
| NPIReactivationDate: | 03/22/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20028 | NE | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | G82066 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10025207400 | 05 | NE | MEDICAID | 4705330312 | 05 | NE | MEDICAID |