Dacosta Medical Group LLC
Organization Active NPI Gastroenterology Physician · Orange, NJ
NPI 1346461282 · NPPES record last updated Apr 23, 2010
Key facts
- NPI
- 1346461282
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Gastroenterology Physician 207RG0100X
- Legal business name
- DACOSTA MEDICAL GROUP LLC
- Practice address
- 85 S Jefferson Street
Orange, NJ 07050 - Phone
- (973) 674-8866
- Fax
- (973) 672-9299
- NPI assigned
- May 1, 2007
- Organization subpart
- No
Authorized official
- Name
- Dr. Theodore Dacosta, MD
- Title
- Physician
- Phone
- (973) 674-8866
Practitioners 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NJ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100414000707 | NJ | Part B Supplier - Clinic/Group Practice | 0244367753 |
Receives reassigned benefits from 2 practitioners Practice locations: West Orange, NJ |
National Provider Directory
Locations
85 S Jefferson St
Orange, NJ 07050
Phone (201) 994-4828
59 Main St
West Orange, NJ 07052
Phone (973) 669-0098
59 Main St
Ste PL1
West Orange, NJ 07052
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Gastroenterology Physician |
207RG0100X | Yes |
Addresses
Primary practice location
85 S Jefferson Street
Orange, NJ 07050
Mailing address
85 S Jefferson Street
Orange, NJ 07050
Phone (973) 674-8866
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 9078908 | Medicaid | NJ |
Other providers in Orange, NJ
- Akilah Crawford
- Cross Counter, Inc
- Abriel Brittney Culver
- D & N Corporation
- D & N Corporation
- Theodore A Dacosta Jr.
- Deidre Dann
- Esther David
- Justein Davis
- DCH Consulting Services, LLC
All providers in 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 Apr 23, 2010. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.