Healthcare Provider Details

I. General information

NPI: 1295948933
Provider Name (Legal Business Name): CYNTHIA LOU COSTENBADER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8136 OLD KEENE MILL RD STE A309
SPRINGFIELD VA
22152-1853
US

IV. Provider business mailing address

DEPT. 453 PO BOX 1000
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-8021
  • Fax: 703-569-8123
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101036748
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: