Provider Demographics
NPI:1417483959
Name:COSTELLO, CLIFFORD (DO)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N. DUNLAP
Mailing Address - Street 2:PEDIATRIC RESIDENCY OFFICE
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103
Mailing Address - Country:US
Mailing Address - Phone:901-287-6756
Mailing Address - Fax:
Practice Address - Street 1:1830 N FRANKLIN ST STE 500
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1169
Practice Address - Country:US
Practice Address - Phone:303-825-8584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0063863208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics