Provider Demographics
NPI:1902904626
Name:DE COSTA, CAROL VR (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:VR
Last Name:DE COSTA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:142 JORALEMON ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4747
Mailing Address - Country:US
Mailing Address - Phone:718-852-6949
Mailing Address - Fax:718-852-7075
Practice Address - Street 1:142 JORALEMON ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4747
Practice Address - Country:US
Practice Address - Phone:718-852-6949
Practice Address - Fax:718-852-7075
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-03-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYA183780208100000X
NY183780208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01862922Medicaid
NY01862922Medicaid
69H721Medicare PIN
NYF57793Medicare UPIN