Organization
DACOSTA MEDICAL GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THEODORE DACOSTA MD (PHYSICIAN)
(973) 674-8866
Entity
Organization
Contact information
Practice address
85 S JEFFERSON STREET, ORANGE, NJ 07050
(973) 674-8866
(973) 672-9299
Mailing address
85 S JEFFERSON STREET, ORANGE, NJ 07050
(973) 674-8866
(973) 672-9299
Taxonomy
Speciality
Code
Description
License number
State
207RG0100X
Gastroenterology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9078908
—
NJ
Enumeration date
05/01/2007
Last updated
04/23/2010
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