Basic Information
| Provider Information | |||||||||
| NPI: | 1649292764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DA COSTA | ||||||||
| FirstName: | DELINE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MENEZES | ||||||||
| OtherFirstName: | DELINE | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3 SALJON CT | ||||||||
| Address2: | |||||||||
| City: | MAPLE GLEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190023012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088476762 | ||||||||
| FaxNumber: | 2157282064 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 ROSEBERRY ST | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088651690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088476762 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | MD428994 | PA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.