Provider Demographics
NPI:1245309970
Name:COSTELLO, SR., JOHN J (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:COSTELLO, SR.
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-1641
Mailing Address - Country:US
Mailing Address - Phone:315-363-4942
Mailing Address - Fax:315-363-4441
Practice Address - Street 1:131 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-1641
Practice Address - Country:US
Practice Address - Phone:315-363-4942
Practice Address - Fax:315-363-4441
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV002717-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02961255Medicaid
NYT26488Medicare UPIN
NYBB1012Medicare PIN
NYAA0047Medicare PIN