Provider Demographics
NPI:1942223698
Name:COSTIN, SCOTT Z (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:Z
Last Name:COSTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-1464
Mailing Address - Country:US
Mailing Address - Phone:937-599-3085
Mailing Address - Fax:
Practice Address - Street 1:130 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-1464
Practice Address - Country:US
Practice Address - Phone:937-599-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-6441-C207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2058866Medicaid
G45670Medicare UPIN