Provider Demographics
NPI:1639148216
Name:COSTELLO, JOSEPH J (DPM)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 N MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-1915
Mailing Address - Country:US
Mailing Address - Phone:570-654-4641
Mailing Address - Fax:570-654-4642
Practice Address - Street 1:45 N MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-1915
Practice Address - Country:US
Practice Address - Phone:570-654-4641
Practice Address - Fax:570-654-4642
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003054L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3610OtherGEISINGER HEALTH PLAN
PA0010811390003Medicaid
P00002482OtherRAILROAD MEDICARE
PA475671OtherPA BLUE SHIELD
PA817167OtherFIRST PRIORITY
PAT82299Medicare UPIN
5512740001Medicare NSC
PA0010811390003Medicaid