Provider Demographics
NPI:1164500112
Name:COSTELLO, JAMIE D (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:D
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 VINCENT CT
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9153
Mailing Address - Country:US
Mailing Address - Phone:732-974-1531
Mailing Address - Fax:
Practice Address - Street 1:53 KENT RD
Practice Address - Street 2:COSTELLO EYE CARE
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731
Practice Address - Country:US
Practice Address - Phone:732-534-5622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00518400152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU34940Medicare UPIN
NJ109496W8AMedicare PIN