Provider Demographics
NPI:1245331818
Name:COSTICH, THEODORE GERARD (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:GERARD
Last Name:COSTICH
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 1:41 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2918
Mailing Address - Country:US
Mailing Address - Phone:716-631-1045
Mailing Address - Fax:716-631-1365
Practice Address - Street 1:41 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2918
Practice Address - Country:US
Practice Address - Phone:716-631-1045
Practice Address - Fax:716-631-1365
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187420207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01406720Medicaid
NY10109001OtherFIDELIS PROVIDER #
NY00020006503OtherUNIVERA HEALTHCARE PROVID
NY0709667OtherINDEPENDENT HEALTH PROVID
NY005250881OtherBC/BS OFWNY PROVIDER #
NY10109001OtherFIDELIS PROVIDER #
NMBB4991Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER