Provider Demographics
NPI:1184720799
Name:COSTELLO, LOUIS E (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:E
Last Name:COSTELLO
Suffix:
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 1:3119 OVERLOOK CIR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-1840
Mailing Address - Country:US
Mailing Address - Phone:972-221-7006
Mailing Address - Fax:972-353-5081
Practice Address - Street 1:190 CIVIC CIR STE 250
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3648
Practice Address - Country:US
Practice Address - Phone:972-436-8591
Practice Address - Fax:972-221-6609
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ19502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113825702Medicaid
TXP0000999JMedicare ID - Type Unspecified
TXF49691Medicare UPIN