Provider Demographics
NPI:1740967967
Name:COSTIN, ALEXANDER (ABO-C)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:COSTIN
Suffix:
Gender:M
Credentials:ABO-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 VAN ALLEN ST SE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49548-1229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:616-534-2909
Practice Address - Street 1:355 54TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-5614
Practice Address - Country:US
Practice Address - Phone:616-552-6228
Practice Address - Fax:616-534-2909
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI250670156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician