Provider Demographics
NPI:1417062563
Name:COSTELLO, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2821 N BALLAS RD
Mailing Address - Street 2:SUITE 165
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2321
Mailing Address - Country:US
Mailing Address - Phone:314-995-9988
Mailing Address - Fax:866-847-8598
Practice Address - Street 1:2821 N BALLAS RD
Practice Address - Street 2:SUITE 165
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2321
Practice Address - Country:US
Practice Address - Phone:314-995-9988
Practice Address - Fax:866-847-8598
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR9162207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154714OtherAETNA SPECIALIST
87043OtherFIRST HEALTH
5502OtherBLUE CROSS BLUE SHIELD MO
112155277OtherRAILROAD MEDICARE
951692OtherAETNA
130260OtherGHP
MO000002229Medicare ID - Type Unspecified
2154714OtherAETNA SPECIALIST