1154300622 NPI number — NOSHIR A DACOSTA MD

Table of content: NOSHIR A DACOSTA MD (NPI 1154300622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154300622 NPI number — NOSHIR A DACOSTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DACOSTA
Provider First Name:
NOSHIR
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154300622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 ROUTE 112 BLDG 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT JEFFERSON STATION
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11776-8055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-751-0000
Provider Business Mailing Address Fax Number:
631-509-6559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48 ROUTE 25A STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11787-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-751-3000
Provider Business Practice Location Address Fax Number:
631-509-6559
Provider Enumeration Date:
01/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  194187 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01813125 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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