Provider Demographics
NPI:1811978414
Name:COSTINO, JOHN G (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:COSTINO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:404 SURF AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH WILDWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08260-5865
Mailing Address - Country:US
Mailing Address - Phone:609-522-8358
Mailing Address - Fax:609-729-8662
Practice Address - Street 1:404 SURF AVE
Practice Address - Street 2:
Practice Address - City:NORTH WILDWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08260-5865
Practice Address - Country:US
Practice Address - Phone:609-522-8358
Practice Address - Fax:609-729-8662
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB02575800204C00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2808501Medicaid
NJ2808501Medicaid
NJC52560Medicare UPIN