Provider Demographics
NPI:1043251184
Name:COSTABLE, JOHN MICHAEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:COSTABLE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:600 NORTHERN BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5200
Mailing Address - Country:US
Mailing Address - Phone:516-466-6075
Mailing Address - Fax:516-466-6044
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:STE 106
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5200
Practice Address - Country:US
Practice Address - Phone:516-466-6075
Practice Address - Fax:516-466-6044
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY198554207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG76623Medicare UPIN
NY98A351Medicare ID - Type Unspecified