Provider Demographics
NPI:1124550496
Name:COSTELLO, JUSTIN ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALEXANDER
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:DEPT OF INTERNAL MEDICINE U OF UTAH MEDICINE
Mailing Address - Street 2:30 NORTH 1900 EAST, ROOM 4C104
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-501-7606
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF UTAH HOSPITAL
Practice Address - Street 2:50 N MEDICAL DRIVE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT10957022-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology