Provider Demographics
NPI:1659570331
Name:COSTELLO, THOMAS P (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:COSTELLO
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 NE 18TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3606
Mailing Address - Country:US
Mailing Address - Phone:267-884-3858
Mailing Address - Fax:
Practice Address - Street 1:2710 NE 18TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-3606
Practice Address - Country:US
Practice Address - Phone:267-884-3858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2025-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6729207LP2900X
PAOS005840L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA564403Medicare PIN
PAE23610Medicare UPIN