Provider Demographics
NPI:1033197116
Name:COSTELLO, DANIEL J (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:60 GLEN ROAD
Mailing Address - Street 2:APT 201W
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7731
Mailing Address - Country:US
Mailing Address - Phone:617-277-1283
Mailing Address - Fax:
Practice Address - Street 1:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - Street 2:WACC 835, 55 FRUIT STREET
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2213672084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2120836Medicaid
MAA39903Medicare ID - Type Unspecified
MAI54429Medicare UPIN