=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497118756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY COSTALES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2016
-----------------------------------------------------
Last Update Date | 10/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3737 MARKET ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-5545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-753-4797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 CITRUS GROVE CT
-----------------------------------------------------
City | NORTH POTOMAC
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878-4918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-753-4797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 286671
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD477449
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------