Provider Demographics
NPI:1235195785
Name:COSTELLO, TIMOTHY D (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
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 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5005
Mailing Address - Country:US
Mailing Address - Phone:904-542-3500
Mailing Address - Fax:
Practice Address - Street 1:620 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2926
Practice Address - Country:US
Practice Address - Phone:870-365-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME137708207P00000X
MO2011003498207P00000X
VA0101236812208D00000X
ARE-7237207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190603001Medicaid
51228OtherAR BLUE CROSS
AR190603001Medicaid