Provider Demographics
NPI:1346245156
Name:COSTELLO, PATRICK A (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:A
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:131 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-1641
Mailing Address - Country:US
Mailing Address - Phone:315-367-0264
Mailing Address - Fax:315-693-0014
Practice Address - Street 1:131 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-1641
Practice Address - Country:US
Practice Address - Phone:315-363-1110
Practice Address - Fax:315-363-4441
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY226080207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB0988Medicare PIN
NYRB0990Medicare PIN
I12036Medicare UPIN
NYP00351667Medicare PIN