Provider Demographics
NPI:1609829662
Name:JOHN J. COSTELLO, JR, DO, PLLC
Entity Type:Organization
Organization Name:JOHN J. COSTELLO, JR, DO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSTELLO, JR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:315-363-1110
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-476-1792
Practice Address - Street 1:578 SENECA ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2600
Practice Address - Country:US
Practice Address - Phone:315-363-1110
Practice Address - Fax:315-363-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01896079Medicaid
NYBB2471Medicare ID - Type UnspecifiedGROUP MEDICARE