Provider Demographics
NPI:1104249580
Name:COSTA, RICARDO JAVIER (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:JAVIER
Last Name:COSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 AMADOR DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4969
Mailing Address - Country:US
Mailing Address - Phone:760-941-3239
Mailing Address - Fax:
Practice Address - Street 1:4905 AMADOR DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4969
Practice Address - Country:US
Practice Address - Phone:760-941-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0A339650174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A339650Medicaid