Provider Demographics
NPI:1134431653
Name:COSTALES, CESAR A (OD, MHA, FAAO)
Entity type:Individual
Prefix:DR
First Name:CESAR
Middle Name:A
Last Name:COSTALES
Suffix:
Gender:M
Credentials:OD, MHA, FAAO
Other - Prefix:DR
Other - First Name:CESAR
Other - Middle Name:A
Other - Last Name:COSTALES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD, MHA, FAAO
Mailing Address - Street 1:450 GIBNER RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE BARRACKS
Mailing Address - State:PA
Mailing Address - Zip Code:17013-5090
Mailing Address - Country:US
Mailing Address - Phone:717-245-3400
Mailing Address - Fax:
Practice Address - Street 1:450 GIBNER RD
Practice Address - Street 2:
Practice Address - City:CARLISLE BARRACKS
Practice Address - State:PA
Practice Address - Zip Code:17013-5090
Practice Address - Country:US
Practice Address - Phone:717-245-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist