Provider Demographics
NPI:1679694723
Name:COSTA, LOUIS E (DO)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:E
Last Name:COSTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 GLENDA RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4922
Mailing Address - Country:US
Mailing Address - Phone:302-505-0045
Mailing Address - Fax:888-873-9653
Practice Address - Street 1:230 BEISER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-7792
Practice Address - Country:US
Practice Address - Phone:302-505-0045
Practice Address - Fax:888-873-9653
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20010788208600000X
PAOS012657208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC2-0010788OtherMEDICAL LICENSE
PA102197454 0003Medicaid
PAOS012657OtherMEDICAL LICENSE