JACK M. COSTA, M.D., P.C. (NPI# 1972808335) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1972808335 |
| Entity Type | Organization |
| Organization Name | JACK M. COSTA, M.D., P.C. |
| Practice Address |
3650 Joseph Siewick Dr Suite 202 Fairfax VA 22033-1710 |
| Practice Telephone | 7033912516 |
| Practice Fax Number | 7034768244 |
| Mailing Telephone | 7033912516 |
| Mailing Fax Number | 7034768244 |
| Enumeration Date | 2011-01-17 |
| Last Update Date | 2011-01-17 |
| Authorized Official Name | DR. JACK M. COSTA (OWNER) |
| Authorized Official Telephone | 7033912516 |
| Authorized Official Credential | M.D. |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 174400000X | Specialist | 0101028288 | VA | Other Service Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| VA | BLUE CROSS BLUE SHIELD | 9320 | 01 |
| VA | ANTHEM | 003539 | 01 |
| Street Address |
3650 JOSEPH SIEWICK DR SUITE 202 |
| City | FAIRFAX |
| State | VA |
| Zip Code | 22033-1710 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1871596692 | Noemi S. Dosova | Pediatrics | 3650 Joseph Siewick Dr, Ste 101, Fairfax, VA 22033-1700 | 2005-05-24 |
| 1215546395 | Ryan Lawson | Nurse Practitioner | 3650 Joseph Siewick Dr, Fairfax, VA 22033-1710 | 2020-07-24 |
| 1043842503 | Shereen A Robinson | Nurse Practitioner | 3650 Joseph Siewick Dr, Fairfax, VA 22033-1710 | 2020-02-12 |
| 1700373982 | Brenda D Carpenter | Pharmacist | 3650 Joseph Siewick Dr, Fairfax, VA 22033-1710 | 2018-04-13 |
| 1487194262 | Molly Boyer Broache | Nurse Practitioner | 3650 Joseph Siewick Dr, Suite 203, Fairfax, VA 22033-1710 | 2017-02-28 |
| 1649714155 | About Care Gyn Associates, Pllc | Clinic/Center | 3650 Joseph Siewick Dr, Suite 309, Fairfax, VA 22033-1710 | 2016-12-19 |
| 1407209307 | Tara Lynne Kiser | Nurse Practitioner | 3650 Joseph Siewick Dr, 400, Fairfax, VA 22033-1710 | 2016-07-15 |
| 1003266552 | Thuy Phuong Thi Vo | Family Medicine | 3650 Joseph Siewick Dr, 400, Fairfax, VA 22033-1710 | 2016-06-15 |
| 1760897342 | Melissa Suzanne Rogina | Advanced Practice Midwife | 3650 Joseph Siewick Dr, Suite 203, Fairfax, VA 22033 | 2014-06-23 |
| 1104230929 | Clare Gosek | Family Medicine | 3650 Joseph Siewick Dr, Suite 400, Fairfax, VA 22033-1710 | 2014-06-19 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1366074320 | Han S Yoo | Pharmacist | 12200 West Ox Road, Fairfax, VA 22033 | 2020-02-07 |
| 1386137271 | Ammar Orthodontics Pllc | Dentist | 11702 Fiar Oaks Mall, Upper Floor, Fairfax, VA 22033 | 2018-06-14 |
| 1013360940 | Kellyn Patricia Dodd | Nurse Practitioner | 3903 Fair Ridge Dr Ste 209, Fairfax, VA 22033 | 2016-07-15 |
| 1659721363 | John Du Od PC | Optometrist | 12618 Victoria Station Ct, Fairfax, VA 22033 | 2016-06-14 |
| 1568861904 | Virginia Cvs Pharmacy LLC | Durable Medical Equipment & Medical Supplies | 12734 Shoppes Lane, Fairfax, VA 22033 | 2014-08-21 |
| 1649696295 | Patrisha Lultschik | Nurse Practitioner | 12375 Lee Jackson Memorial Hwy, Fairfax, VA 22033 | 2014-03-06 |
| 1912321910 | Alyson Huber | Nurse Anesthetist, Certified Registered | 3600 Joseph Siewick Dr., Fairfax, VA 22033 | 2014-02-11 |
| 1578999314 | Aiatulah Surmaty | Optometrist | 11801 Lee Jackson Memorial Hwy, Fairfax, VA 22033 | 2013-09-25 |
| 1356780928 | Ayatallah M. Khafagy | Obstetrics & Gynecology | 3650 Joseph Siewick Dr Suite 203, Fairfax, VA 22033 | 2013-06-17 |
| 1760726665 | Michelle Elise Schwartz | Speech-Language Pathologist | 3507 Curtice Farm Dr, Fairfax, VA 22033 | 2012-11-15 |
| Find all providers in zip 22033 | ||||
| Taxonomy Code | 174400000X |
| Grouping | Other Service Providers |
| Classification | Specialist |
| An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |
| Notes: Source: Expanded from Webster’s II New Riverside University Dictionary, Boston: Riverside Publishing Company, 1974. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1841748829 | Katherine Thompson | Specialist | 3525 Mclean Ave, Fairfax, VA 22030-3007 | 2016-09-19 |
| 1932574019 | Tracie Reyes | Specialist | 11240 Waples Mill Rd Ste 100, Fairfax, VA 22030-6078 | 2015-12-01 |
| 1669845236 | Lauren Washington | Specialist | 11240 Waples Mill Rd Ste 301, Fairfax, VA 22030-6078 | 2015-11-04 |
| 1457746513 | Stephanie Bolger | Specialist | 10700 Zion Dr, Fairfax, VA 22032-3432 | 2015-04-05 |
| 1588066096 | Erin Stephenson | Specialist | 12881 Fair Valley Ct, Fairfax, VA 22033-3816 | 2014-09-16 |
| 1609114081 | Rachel Fannell Eisenfeld | Specialist | 10660 Page Ave, Fairfax, VA 22030-4098 | 2013-01-20 |
| 1043563422 | Maryann G Rozzell | Specialist | 3422 Barkley Dr, Fairfax, VA 22031-2724 | 2012-10-22 |
| 1861776551 | Wilbert Aguila | Specialist | 12678 Marcum Ct, Fairfax, VA 22033-2457 | 2011-09-29 |
| 1558692681 | Jacquelyn Lewis | Specialist | 1193 Ethan Allen Hwy, Fairfax, VT 05454-5433 | 2010-01-29 |
| 1861679896 | Linda O'toole Glick | Specialist | 11106 Del Rio Dr, Fairfax, VA 22030-5339 | 2008-01-22 |
| Find all providers in FAIRFAX | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.