Provider Demographics
NPI:1760498901
Name:COSTELLO, JAMES W (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:COSTELLO
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 1:3626 RUFFIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1810
Mailing Address - Country:US
Mailing Address - Phone:858-565-9666
Mailing Address - Fax:858-565-9441
Practice Address - Street 1:3626 RUFFIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1810
Practice Address - Country:US
Practice Address - Phone:858-565-9666
Practice Address - Fax:858-565-9441
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72673207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A726730Medicaid
CA00A726730OtherBLUE SHIELD OF CA
CAWA72673AMedicare PIN
CAH58484Medicare UPIN