Provider Demographics
NPI:1265491302
Name:COSTNER, MELISSA I (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:I
Last Name:COSTNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17051 DALLAS PKWY STE 350
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-7107
Mailing Address - Country:US
Mailing Address - Phone:214-702-0029
Mailing Address - Fax:214-382-3453
Practice Address - Street 1:17051 DALLAS PKWY STE 350
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7107
Practice Address - Country:US
Practice Address - Phone:214-702-0029
Practice Address - Fax:214-382-3453
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5980207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G02267Medicare UPIN
TXC00879988Medicare ID - Type Unspecified