Healthcare Provider Details

I. General information

NPI: 1952629065
Provider Name (Legal Business Name): VANESSA CRYSTAL COSTILLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 09/23/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 102ND ST
LUBBOCK TX
79423
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0747
  • Fax: 806-761-0751
Mailing address:
  • Phone: 806-761-0333
  • Fax: 806-785-7685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberP5951
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: