Healthcare Provider Details

I. General information

NPI: 1841257540
Provider Name (Legal Business Name): JAMES MITCHELL COSTNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 CLEVELAND AVE
KINGS MOUNTAIN NC
28086-3106
US

IV. Provider business mailing address

214 N. CLEVELAND AVE.
KINGS MOUNTAIN NC
28086-3106
US

V. Phone/Fax

Practice location:
  • Phone: 704-730-1228
  • Fax: 704-730-1231
Mailing address:
  • Phone: 704-730-1228
  • Fax: 704-730-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9400760
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: