Provider Demographics
NPI:1548336605
Name:D'COSTA, WALTER FRANCIS (DPM)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:FRANCIS
Last Name:D'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 1:2281 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2905
Mailing Address - Country:US
Mailing Address - Phone:707-544-3337
Mailing Address - Fax:707-544-0608
Practice Address - Street 1:2281 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2905
Practice Address - Country:US
Practice Address - Phone:707-544-3337
Practice Address - Fax:707-544-0608
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHC116746213ER0200X
CAE2603213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
756480842OtherRAILROAD MEDICARE
CA000E26030Medicaid
170924000OtherUS DEPARTMENT OF LABOR
CA000E26030Medicare ID - Type Unspecified
CA6598120001Medicare NSC
756480842OtherRAILROAD MEDICARE