Provider Demographics
NPI:1942401039
Name:FISCHER COSTELLO, LONDA LEA (OD)
Entity Type:Individual
Prefix:DR
First Name:LONDA
Middle Name:LEA
Last Name:FISCHER COSTELLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13334 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4540
Mailing Address - Country:US
Mailing Address - Phone:320-212-0500
Mailing Address - Fax:
Practice Address - Street 1:13334 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4540
Practice Address - Country:US
Practice Address - Phone:763-496-1625
Practice Address - Fax:763-496-1071
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist