Provider Demographics
NPI:1376540435
Name:COSTELLO, LAURIE J (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
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 1:180 E PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1915
Mailing Address - Country:US
Mailing Address - Phone:631-425-2121
Mailing Address - Fax:631-425-2193
Practice Address - Street 1:180 E PULASKI RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1915
Practice Address - Country:US
Practice Address - Phone:631-425-2121
Practice Address - Fax:631-425-2193
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191191-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01592465Medicaid
NY669781Medicare PIN
NY01592465Medicaid