MEDICARE: JOHN L. COSTELLO OD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	27OA00518500	NJ

General Provider Information

NPI Number	:	1447478730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN L. COSTELLO OD PA

Provider Business Mailing Address
First Line	:	1930 VINCENT CT
Second Line	:
City	:	WALL TOWNSHIP
State	:	NJ
Zip	:	07719-9153
Country	:	US
Telephone Number	:	732-974-1531
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 KENT RD
Second Line	:
City	:	HOWELL
State	:	NJ
Zip	:	07731-2452
Country	:	US
Telephone Number	:	732-534-5622
Fax Number	:	732-534-5620

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN L COSTELLO JR.
Credential	:	O.D.
Telephone Number	:	732-534-5622

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	11/23/2007

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