Provider Demographics
NPI:1144393935
Name:COSTA, JACK MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MICHAEL
Last Name:COSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3650 JOSEPH SIEWICK DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-391-2516
Mailing Address - Fax:703-476-8244
Practice Address - Street 1:3650 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1710
Practice Address - Country:US
Practice Address - Phone:703-391-2516
Practice Address - Fax:703-476-8244
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101028288207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9320OtherBLUE CROSS BLUE SHIELD
VA003539OtherANTHEM
409274Medicare ID - Type Unspecified
C62572Medicare UPIN