Provider Demographics
NPI:1477590560
Name:COSTELLO, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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 1:2020 PALOMINO LN
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4894
Mailing Address - Country:US
Mailing Address - Phone:702-759-8600
Mailing Address - Fax:702-384-1815
Practice Address - Street 1:2020 PALOMINO LN
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4894
Practice Address - Country:US
Practice Address - Phone:702-759-8600
Practice Address - Fax:702-384-1815
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV55272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV200290011Medicaid
OK200470490AMedicaid
CA1477590560Medicaid
NVC95915Medicare UPIN
NVFW768YMedicare PIN
NVFW768ZMedicare PIN
OK200470490AMedicaid