Provider Demographics
NPI:1841301611
Name:COSTELLO, GABRIELLE JEANNE (MD)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:JEANNE
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 1:1761 ODESSA LN
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-2624
Mailing Address - Country:US
Mailing Address - Phone:215-369-4884
Mailing Address - Fax:
Practice Address - Street 1:680 HEACOCK RD STE 101
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-6346
Practice Address - Country:US
Practice Address - Phone:215-493-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047714L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F 67040Medicare UPIN