Provider Demographics
NPI:1700832011
Name:COSTLEY, CHAD DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:DONALD
Last Name:COSTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W PONCE DE LEON AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2441
Mailing Address - Country:US
Mailing Address - Phone:404-537-2521
Mailing Address - Fax:678-515-4653
Practice Address - Street 1:315 W PONCE DE LEON AVE STE 110
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2441
Practice Address - Country:US
Practice Address - Phone:404-371-9673
Practice Address - Fax:844-246-7292
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH48955Medicare UPIN