Provider Demographics
NPI:1417281163
Name:COSTON, WANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:
Last Name:COSTON
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 1:125 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5125
Mailing Address - Country:US
Mailing Address - Phone:215-592-4500
Mailing Address - Fax:
Practice Address - Street 1:125 S 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5125
Practice Address - Country:US
Practice Address - Phone:215-592-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD441753207R00000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program