Provider Demographics
NPI:1114420155
Name:DACOSTA, THEODORE R (DO)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:R
Last Name:DACOSTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 MCCHESNEY CT
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1135
Mailing Address - Country:US
Mailing Address - Phone:973-699-3950
Mailing Address - Fax:
Practice Address - Street 1:59 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5341
Practice Address - Country:US
Practice Address - Phone:973-674-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
NJ25MB12193600207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program