Individual
JACK MICHAEL COSTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3650 JOSEPH SIEWICK DR, SUITE 202, FAIRFAX, VA 22033-1710
(703) 391-2516
(703) 476-8244
Mailing address
3650 JOSEPH SIEWICK DRIVE, SUITE 202, FAIRFAX, VA 22033
(703) 391-2516
(703) 476-8244
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
0101028288
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003539
ANTHEM
VA
01
—
9320
BLUE CROSS BLUE SHIELD
VA
Enumeration date
11/17/2006
Last updated
12/30/2010
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