Provider Demographics
NPI:1467943068
Name:COSTALES, ALVIN
Entity Type:Individual
Prefix:MR
First Name:ALVIN
Middle Name:
Last Name:COSTALES
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 1:918 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-2860
Mailing Address - Country:US
Mailing Address - Phone:240-437-8211
Mailing Address - Fax:
Practice Address - Street 1:918 W 20TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-2860
Practice Address - Country:US
Practice Address - Phone:240-437-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1299740208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX953873894OtherUNITED HEALTHCARE