Provider Demographics
NPI:1477679413
Name:COSTELLO, ROBERT EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9876 QUEENS BLVD
Mailing Address - Street 2:1-F
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4356
Mailing Address - Country:US
Mailing Address - Phone:718-275-4194
Mailing Address - Fax:718-275-4191
Practice Address - Street 1:9876 QUEENS BLVD
Practice Address - Street 2:1-F
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4356
Practice Address - Country:US
Practice Address - Phone:718-275-4194
Practice Address - Fax:718-275-4191
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2105-7111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor