Provider Demographics
NPI:1265578280
Name:COSTELLO, VICTORIA WALKER (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:WALKER
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8020
Mailing Address - Country:US
Mailing Address - Phone:860-679-8400
Mailing Address - Fax:860-679-8188
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-8400
Practice Address - Fax:860-679-8188
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066714A207R00000X, 208M00000X
CT54555207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200959610Medicaid
IN200959610Medicaid