Provider Demographics
NPI:1518438753
Name:COSTELLO, MELINDA H (COTA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:H
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-3104
Mailing Address - Country:US
Mailing Address - Phone:203-924-7866
Mailing Address - Fax:203-513-8424
Practice Address - Street 1:18 CENTER ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-3104
Practice Address - Country:US
Practice Address - Phone:203-924-7866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT19392081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine