Provider Demographics
NPI:1487650743
Name:COSTELLO, JOHN J JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:COSTELLO
Suffix:JR
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 1:131 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-1641
Mailing Address - Country:US
Mailing Address - Phone:315-367-0264
Mailing Address - Fax:315-693-0014
Practice Address - Street 1:131 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-1641
Practice Address - Country:US
Practice Address - Phone:315-367-0264
Practice Address - Fax:315-693-0014
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194090207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB0987Medicare PIN
F98016Medicare UPIN
NYP00384076Medicare PIN
NYRB0989Medicare PIN