Provider Demographics
NPI:1770720468
Name:COSTELLO SR - ALLEN OPTOMETRISTS PLLC
Entity type:Organization
Organization Name:COSTELLO SR - ALLEN OPTOMETRISTS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-363-4942
Mailing Address - Street 1:131 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-1641
Mailing Address - Country:US
Mailing Address - Phone:315-363-4942
Mailing Address - Fax:
Practice Address - Street 1:131 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-1641
Practice Address - Country:US
Practice Address - Phone:315-363-4942
Practice Address - Fax:315-363-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006206152W00000X
NYTUV007184152W00000X
NYTUV006131152W00000X
NYTUV005917-1152W00000X
NYTUV008323-1152W00000X
NYTUV002717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02924674Medicaid
NY02961255Medicaid
NY02302867Medicaid
NY410039620OtherRAILROAD MEDICARE
NYP00620900Medicare PIN
NY6238120002Medicare NSC
NYBB1012Medicare PIN
NY02924674Medicaid
NY410039620OtherRAILROAD MEDICARE
NYAA0047Medicare PIN
NY02961255Medicaid
NYDD4423Medicare PIN