Provider Demographics
NPI:1255644787
Name:COSTELLO, JOSEPH KENNEDY IV (MD)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:KENNEDY
Last Name:COSTELLO
Suffix:IV
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 1:224 N. 49TH ST. #4A
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132
Mailing Address - Country:US
Mailing Address - Phone:402-659-4247
Mailing Address - Fax:
Practice Address - Street 1:224 N. 49TH ST. #4A
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68132
Practice Address - Country:US
Practice Address - Phone:402-659-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEPENDING208D00000X
NE25900208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice