Provider Demographics
NPI:1609961887
Name:COSTON, SEAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:D
Last Name:COSTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:201 CEDAR NE
Practice Address - Street 2:PMG CEDAR SURGERY SUITE 306
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-563-1000
Practice Address - Fax:505-247-2934
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM20020306208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78136318Medicaid
H72266Medicare UPIN
344328102Medicare PIN