Healthcare Provider Details

I. General information

NPI: 1114002995
Provider Name (Legal Business Name): MICHAEL J COSTELLO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 NEBRASKA AVE SUITE 3-D
FORT PIERCE FL
34950-4864
US

IV. Provider business mailing address

2215 NEBRASKA AVE SUITE 3-D
FORT PIERCE FL
34950-4864
US

V. Phone/Fax

Practice location:
  • Phone: 772-461-4666
  • Fax: 772-464-3005
Mailing address:
  • Phone: 772-461-4666
  • Fax: 772-464-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0026473
License Number StateFL

VIII. Authorized Official

Name: MICHAEL J COSTELLO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 772-461-4666