Provider Demographics
NPI:1417955600
Name:COSTARELLI, LAURIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:
Last Name:COSTARELLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 EAST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1846
Mailing Address - Country:US
Mailing Address - Phone:570-387-8800
Mailing Address - Fax:570-784-8887
Practice Address - Street 1:301 EAST ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1846
Practice Address - Country:US
Practice Address - Phone:570-387-8800
Practice Address - Fax:570-784-8887
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01491501OtherCAPITAL BLUE CROSS
PA067283OtherKEYSTONE HEALTH PLAN CENT
PAC0067283OtherBLUE SHIELD
PA816234OtherFIRST PRIORITY HEALTH
PA01491501OtherCAPITAL BLUE CROSS
PA816234OtherFIRST PRIORITY HEALTH