Provider Demographics
NPI:1285851337
Name:COSTELLO, FREDERICK M (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:M
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 1:8854 W EMERALD ST STE 260
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4860
Mailing Address - Country:US
Mailing Address - Phone:208-398-4306
Mailing Address - Fax:
Practice Address - Street 1:8854 W EMERALD ST STE 260
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4860
Practice Address - Country:US
Practice Address - Phone:208-398-4306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400112207R00000X
IDM10231207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine