Healthcare Provider Details

I. General information

NPI: 1619266897
Provider Name (Legal Business Name): JESSE LEE COSTALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 W MCRAE WAY
PHOENIX AZ
85027-4915
US

IV. Provider business mailing address

3009 W MCRAE WAY
PHOENIX AZ
85027-4915
US

V. Phone/Fax

Practice location:
  • Phone: 602-353-2340
  • Fax:
Mailing address:
  • Phone: 909-772-2963
  • Fax: 94-067-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number58656
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: