MEDICARE: JUSTIN COSTELLO D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	973	NE
2	2085R0202X	Diagnostic Radiology Physician	R3055	TX
3	2085R0204X	Vascular & Interventional Radiology Physician	R3055	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215235916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN COSTELLO D.O.

Provider Business Mailing Address
First Line	:	3851 ROGER BROOKE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-4500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3851 ROGER BROOKE DRIVE, FORT SAM HOUSTON
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-6200
Country	:	US
Telephone Number	:	210-916-5545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2011
Last Update Date	:	06/12/2026

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Directions to “ JUSTIN COSTELLO D.O.” Practice Location

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