| Dacosta Medical Group Llc | |
|
85 S Jefferson Street Orange NJ 07050 | |
| (973) 674-8866 | |
| (973) 672-9299 |
| Full Name | Dacosta Medical Group Llc |
|---|---|
| Speciality | Internal Medicine |
| Location | 85 S Jefferson Street, Orange, New Jersey |
| Authorized Official Name and Position | Theodore Dacosta (PHYSICIAN) |
| Authorized Official Contact | 9736748866 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Dacosta Medical Group Llc 85 S Jefferson Street Orange NJ 07050 Ph: (973) 674-8866 | Dacosta Medical Group Llc 85 S Jefferson Street Orange NJ 07050 Ph: (973) 674-8866 |
| NPI Number | 1346461282 |
|---|---|
| Provider Enumeration Date | 05/01/2007 |
| Last Update Date | 04/23/2010 |
| Medicare PECOS PAC ID | 0244367753 |
|---|---|
| Medicare Enrollment ID | O20100414000707 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1346461282 | NPI | - | NPPES |
| 9078908 | Medicaid | NJ |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207RG0100X | Internal Medicine - Gastroenterology | (* (Not Available)) | Primary |
| Provider Name | Theodore A Dacosta |
|---|---|
| Provider Type | Practitioner - Gastroenterology |
| Provider Identifiers | NPI Number: 1558395673 PECOS PAC ID: 9931144821 Enrollment ID: I20050622000030 |
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