MEDICARE: DR. HOLLY BRIANN COSTNER D.O.

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	207P00000X	Emergency Medicine Physician	4709	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4709	OTHER	OK	MEDICAL LICENSE

General Provider Information

NPI Number	:	1912159492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOLLY BRIANN COSTNER D.O.

Provider Business Mailing Address
First Line	:	4200 S DOUGLAS AVE
Second Line	:	STE 306
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-3223
Country	:	US
Telephone Number	:	405-636-7195
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 S DOUGLAS AVE
Second Line	:	STE 306
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-3223
Country	:	US
Telephone Number	:	405-636-7195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2008
Last Update Date	:	02/08/2011

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