Healthcare Provider Details

I. General information

NPI: 1043748072
Provider Name (Legal Business Name): ANNA COSTELOE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANYA COSTELOE

II. Dates (important events)

Enumeration Date: 06/04/2017
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WATERFRONT ST STE 400
NATIONAL HARBOR MD
20745-1142
US

IV. Provider business mailing address

120 WATERFRONT ST STE 400
NATIONAL HARBOR MD
20745-1142
US

V. Phone/Fax

Practice location:
  • Phone: 301-567-6767
  • Fax:
Mailing address:
  • Phone: 301-567-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number20A19296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: