Provider Demographics
NPI:1184202806
Name:COSTELLO, JOHN STANTON III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STANTON
Last Name:COSTELLO
Suffix:III
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 1:10790 RANCHO BERNARDO RD # 4S-205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-3200
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA185144208D00000X, 208M00000X, 207RG0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program