Basic Information
| Provider Information | |||||||||
| NPI: | 1972526960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DACOSTA | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1628 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928560628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146194730 | ||||||||
| FaxNumber: | 7145601585 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 W STEWART DR | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146339111 | ||||||||
| FaxNumber: | 7147448695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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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 | 207L00000X | A91285 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A912850 | 05 | CA | MEDICAID | 00A912850 | 01 | CA | BLUE SHIELD | OTHER |