Provider Demographics
NPI:1053374827
Name:DCOSTA, MATIAS M (MD)
Entity type:Individual
Prefix:
First Name:MATIAS
Middle Name:M
Last Name:DCOSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 HALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1228
Mailing Address - Country:US
Mailing Address - Phone:631-331-7200
Mailing Address - Fax:631-331-8636
Practice Address - Street 1:931 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1228
Practice Address - Country:US
Practice Address - Phone:631-331-7200
Practice Address - Fax:631-331-8636
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75168207R00000X
NY1764091207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4311771Medicare ID - Type Unspecified
F50607Medicare UPIN