| Doctor Name: | PETRONILO R COSTA |
| NPI Number: | 1043435340 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 3646108 |
| Business Practice Address: | 420 Lake Cook Rd Ste 118 Deerfield, IL - 600154914 |
| Business Phone Number: | 8472050237 |
| Business Fax Number: | 8667353898 |
| Mailing Address: | 420 Lake Cook Rd Ste 118, DEERFIELD |
| State: | IL |
| Postal Code: | 600154914 |
| Phone Number: | 8472050237 |
| Fax Number: | 8667353898 |
| NPI Enumeration Date: | 04/13/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TP0016X |
| License Number: | 3646108 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Prescribing (Medical) |
| Taxonomy Definition: | Those licensed psychologists who have completed specialized, post-doctoral training in psychopharmacology, passed a national proficiency examination in psychopharmacology, and who are authorized by state statute to prescribe medications, in accordance with their state law and state licensing authority, for the evaluation, diagnosis, management and treatment of mental, nervous, emotional, behavioral, and related disorders. |