Provider Demographics
NPI:1770748865
Name:COSTELLO, AGNES KATHERINE (MD)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:KATHERINE
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 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-6631
Mailing Address - Fax:630-933-4936
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-6631
Practice Address - Fax:630-933-4936
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361177002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117700Medicaid
IL206147OtherMEDICARE (GROUP)
IL206147218OtherMEDICARE PTAN (INDIVIDUAL)