=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700832011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD DONALD COSTLEY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 01/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 W PONCE DE LEON AVE STE 110
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-371-9673
-----------------------------------------------------
Fax | 844-246-7292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 W PONCE DE LEON AVE STE 110
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-537-2521
-----------------------------------------------------
Fax | 678-515-4653
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 054263
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------