Provider Demographics
NPI:1881658185
Name:COSTELLO, JOHN MILTON JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MILTON
Last Name:COSTELLO
Suffix:JR
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 1:125 N FRANKLIN DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-5892
Mailing Address - Country:US
Mailing Address - Phone:724-225-6500
Mailing Address - Fax:724-225-8188
Practice Address - Street 1:125 N FRANKLIN DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-5892
Practice Address - Country:US
Practice Address - Phone:724-225-6500
Practice Address - Fax:724-229-2170
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036851E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
0162212OtherBS
PA0011237940001Medicaid
0162212OtherBS
C32445Medicare UPIN