Provider Demographics
NPI:1679990170
Name:COSTA, CRAIG (DPM)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MORRIS AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1427
Mailing Address - Country:US
Mailing Address - Phone:973-258-0111
Mailing Address - Fax:973-258-0122
Practice Address - Street 1:100 MORRIS AVE STE 304
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1427
Practice Address - Country:US
Practice Address - Phone:973-258-0111
Practice Address - Fax:973-258-0122
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MD00331500213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program