Provider Demographics
NPI:1821270521
Name:JOSEPH J. COSTELLO DPM
Entity Type:Organization
Organization Name:JOSEPH J. COSTELLO DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-654-4641
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-003054-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00002482OtherRR MCR
P00002482OtherRR MCR