Provider Demographics
NPI:1053302992
Name:COSTELLO, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:603-893-8886
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217260208000000X
SC526862080P0202X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2014416Medicaid
MA97288001OtherNETWORK HEALTH
MATUFTS HEALTH PLANOther217260
RIJC51504Medicaid
MA25-01706OtherUNITED HEALTHCARE MA
MAJ26530OtherHMO BLUE
MA3253447OtherAETNA MA
MA26528OtherBMC HEALTHNET
MA32292OtherNEIGHBORHOOD HEALTH PLAN
MAAA9211OtherHARVARD PILGRIM
MAJ26530OtherBCBS MA
MAJ26530OtherBLUE CARE ELECT
MA32292OtherNEIGHBORHOOD HEALTH PLAN
MAJ26530OtherBLUE CARE ELECT