Provider Demographics
NPI:1114969631
Name:COSTIN, LINDA A (DO)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:COSTIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:FANNIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 DOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 DOWELL AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2305
Practice Address - Country:US
Practice Address - Phone:937-593-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006035208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0007901038OtherAETNA
OH2044255Medicaid
000000212780OtherANTHEM
408680000EOtherNATIONWIDE
12-01787OtherUHC
1956150005OtherCIGNA