Provider Demographics
NPI:1437271251
Name:COSTNER, WILLIAM M
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:COSTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:BESSEMER CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28016
Mailing Address - Country:US
Mailing Address - Phone:704-629-3223
Mailing Address - Fax:704-629-3223
Practice Address - Street 1:127 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BESSEMER CITY
Practice Address - State:NC
Practice Address - Zip Code:28016
Practice Address - Country:US
Practice Address - Phone:704-629-3223
Practice Address - Fax:704-629-3223
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909186Medicaid
NCP00154610OtherRAILROAD PIN NUMBER MEDIC
NC09186OtherNC HEALTH CHOICE
NCT64602Medicare UPIN
NC09186OtherNC HEALTH CHOICE
NC8909186Medicaid