Jack M. Costa, M.D., P.C.

Primary specialty

SpecialistTaxonomy code 174400000X

License

0101028288 Issued in VA

Legal business name

JACK M. COSTA, M.D., P.C.

Practice address

3650 Joseph Siewick Dr
Suite 202
Fairfax, VA 22033-1710

Phone

(703) 391-2516

Fax

(703) 476-8244

NPI assigned

Jan 17, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jack M. Costa, M.D.NPI 1144393935

Title

Owner

Phone

(703) 391-2516

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in DC

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jack Michael Costa, M.D.

  • Dermatology Physician
  • Fairfax, VA
  • NPI 1144393935

  DC

  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1295222400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1295222400000",
    "number": "1972808335",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3650 JOSEPH SIEWICK DR",
            "address_2": "SUITE 202",
            "city": "FAIRFAX",
            "state": "VA",
            "postal_code": "220331710",
            "telephone_number": "703-391-2516",
            "fax_number": "703-476-8244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3650 JOSEPH SIEWICK DR",
            "address_2": "SUITE 202",
            "city": "FAIRFAX",
            "state": "VA",
            "postal_code": "220331710",
            "telephone_number": "703-391-2516",
            "fax_number": "703-476-8244"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACK M. COSTA, M.D., P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-17",
        "last_updated": "2011-01-17",
        "status": "A",
        "authorized_official_last_name": "COSTA",
        "authorized_official_first_name": "JACK",
        "authorized_official_middle_name": "M.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "703-391-2516",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "VA",
            "license": "0101028288",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS  BLUE SHIELD",
            "identifier": "9320",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "003539",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• J.Lawrence Jamieson,PH.D.,P.C.
• J&C Healthcare LLC
• Rolla Jaber, M.D.
• Jessica Jabola, MD
• Ruby Rosa P Jacinto, NP
• Gabriella T Jack, NCC, LPC
• Beth Jackson, MSW, M.ED.
• Charles E. Jackson, FNP-C
• Claressa O Jackson, OTR/L
• Cynthia M Jackson

• Specialist in Fairfax, VA
• Providers in Fairfax, VA by specialty
• Specialist in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 17, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.