Provider Demographics
NPI:1962060517
Name:COSTA, SERGIO (CO)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 BUBECK CT
Mailing Address - Street 2:
Mailing Address - City:IVYLAND
Mailing Address - State:PA
Mailing Address - Zip Code:18974-1288
Mailing Address - Country:US
Mailing Address - Phone:215-330-2711
Mailing Address - Fax:
Practice Address - Street 1:70 BUBECK CT
Practice Address - Street 2:
Practice Address - City:IVYLAND
Practice Address - State:PA
Practice Address - Zip Code:18974-1288
Practice Address - Country:US
Practice Address - Phone:215-330-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty