Healthcare Provider Details

I. General information

NPI: 1609961887
Provider Name (Legal Business Name): SEAN D COSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR NE PMG CEDAR SURGERY SUITE 306
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-1000
  • Fax: 505-247-2934
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20020306
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: