Healthcare Provider Details

I. General information

NPI: 1851355374
Provider Name (Legal Business Name): JOHN G COSTINO DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 SURF AVE
NORTH WILDWOOD NJ
08260-5865
US

IV. Provider business mailing address

404 SURF AVE
NORTH WILDWOOD NJ
08260-5865
US

V. Phone/Fax

Practice location:
  • Phone: 609-522-8358
  • Fax:
Mailing address:
  • Phone: 609-522-8358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB02575800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMB02575800
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN G COSTINO
Title or Position: OWNER
Credential: DO
Phone: 609-522-8358