Provider Demographics
NPI:1801883236
Name:COSTELLO, JAMES (PA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 PRESCOTT RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8418
Mailing Address - Country:US
Mailing Address - Phone:209-544-7300
Mailing Address - Fax:209-544-7323
Practice Address - Street 1:4120 PRESCOTT RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8418
Practice Address - Country:US
Practice Address - Phone:209-544-7300
Practice Address - Fax:209-544-7323
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA10823208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMC0665135OtherDEA