Theodore R Dacosta, DO
Individual provider Active NPI Gastroenterology Physician · West Orange, NJ
NPI 1114420155 · NPPES record last updated May 30, 2024
Key facts
- NPI
- 1114420155
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Gastroenterology Physician 207RG0100X
- License
- 25MB12193600 (NJ)
- Practice address
- 59 Main St Ste 1
West Orange, NJ 07052-5341 - Phone
- (973) 674-8866
- NPI assigned
- Mar 15, 2018
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NJ
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240821000444 | NJ | Practitioner - Gastroenterology |
0547708646 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Osteopathy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 25MB12193600 | NJ | MD | Gastroenterology Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Dacosta Medical Group LLC | Gastroenterology | Current |
Accepting new patients |
Locations
59 Main St
Ste PL1
West Orange, NJ 07052
59 Main St
Ste 1
West Orange, NJ 07052
Phone (973) 638-1740
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | NJ | ||
| Gastroenterology Physician | 207RG0100X | 25MB12193600 | NJ | Yes |
Addresses
Primary practice location
59 Main St Ste 1
West Orange, NJ 07052-5341
Mailing address
26 McChesney CT
West Orange, NJ 07052-1135
Phone (973) 699-3950
Other practice location 1
26 McChesney Ct
West Orange, NJ 07052-1135
Phone (973) 699-3950
Other providers in West Orange, NJ
- Kristen Cunningham
- Cypress Health Institute of New Jersey
- Yolanda Czerniawski
- Kelly Elizabeth D'Urso
- Marissa G D'Urso
- Courtney Dalebroux
- Nicholas Dalonzo
- Daniel Edelman, Psy.D.P.C.
- Megan Daniels
- Dans Music Studio
All providers in West Orange, NJ · Gastroenterology Physician in New Jersey
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 30, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.