Healthcare Provider Details

I. General information

NPI: 1366470403
Provider Name (Legal Business Name): MICHAEL J COSTELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2215 NEBRASKA AVE SUITE 3D
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
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME0026473
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME0026473
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: