Costa, Jack Michael

Costa, Jack Michael is an sole proprietor health care provider with primary practice located at 3650 Joseph Siewick Dr Suite 202, Fairfax VA 22033-1710. He recently has only one registered license in Allopathic & Osteopathic Physicians / Dermatology, which is considered as his primary health care specialty. Costa, Jack Michael can be contacted via phone (703) 391-2516.

Contact Information

Primary practice address
3650 Joseph Siewick Dr Suite 202 Fairfax VA 22033-1710
Phone: (703) 391-2516
Fax: (703) 476-8244
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Dermatology 207N00000X 0101028288 Virginia

Profile Details

NPI number 1144393935
LBN Legal business name Costa, Jack Michael
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Nov 17th, 2006
Last updated Dec 30th, 2010 - about 14 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1144393935 NPPES
Virginia Other 9320 BLUE CROSS BLUE SHIELD
Virginia Other 003539 BLUE CROSS BLUE SHIELD

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