1245309970 NPI number — JOHN J. COSTELLO, SR. O.D.

Table of content: (NPI 1871069666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245309970 NPI number — JOHN J. COSTELLO, SR. O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTELLO, SR.
Provider First Name:
JOHN
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245309970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
ONEIDA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13421-1641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-363-4942
Provider Business Mailing Address Fax Number:
315-363-4441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ONEIDA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13421-1641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-363-4942
Provider Business Practice Location Address Fax Number:
315-363-4441
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TUV002717-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02961255 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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