Provider Demographics
NPI:1982788394
Name:DACOSTA, GASTON F (MD)
Entity type:Individual
Prefix:
First Name:GASTON
Middle Name:F
Last Name:DACOSTA
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 1:117 N. MECHANIC STREET
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619
Mailing Address - Country:US
Mailing Address - Phone:315-493-3100
Mailing Address - Fax:315-493-3113
Practice Address - Street 1:117 N. MECHANIC STREET
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619
Practice Address - Country:US
Practice Address - Phone:315-493-3100
Practice Address - Fax:315-493-3113
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188409207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01503075Medicaid
NY01503075Medicaid
F60122Medicare UPIN
NYF60122Medicare UPIN