Provider Demographics
NPI:1326292269
Name:COSTELLO, LEAH MCLANE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:MCLANE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BLAIR PARK RD STE 285
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7586
Mailing Address - Country:US
Mailing Address - Phone:802-288-1140
Mailing Address - Fax:802-288-1144
Practice Address - Street 1:51 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5201
Practice Address - Country:US
Practice Address - Phone:802-864-0521
Practice Address - Fax:802-864-6475
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0012834208000000X
UT7148432-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1026302Medicaid