Basic Information
| Provider Information | |||||||||
| NPI: | 1619080611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11131 JOURNAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | KING GEORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406252527 | ||||||||
| FaxNumber: | 5407097211 | ||||||||
| Practice Location | |||||||||
| Address1: | 11131 JOURNAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | KING GEORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407857810 | ||||||||
| FaxNumber: | 5407863099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101052199 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619080611 | 05 | VA | MEDICAID |