Provider Demographics
NPI:1790289197
Name:COSTABLE, NICHOLAS JOHN (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:COSTABLE
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 1:351 E 84TH ST APT 21C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4457
Mailing Address - Country:US
Mailing Address - Phone:516-987-0794
Mailing Address - Fax:
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2025-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303919207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology