MEDICARE: DR. LAURIE COSTARELLI OD

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	152W00000X	Optometrist	OEG000097	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01491501	OTHER	PA	CAPITAL BLUE CROSS
2	067283	OTHER	PA	KEYSTONE HEALTH PLAN CENT
3	C0067283	OTHER	PA	BLUE SHIELD
4	816234	OTHER	PA	FIRST PRIORITY HEALTH

General Provider Information

NPI Number	:	1417955600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURIE COSTARELLI OD

Provider Business Mailing Address
First Line	:	301 EAST ST
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-1846
Country	:	US
Telephone Number	:	570-387-8800
Fax Number	:	570-784-8887

Provider Business Practice Location Address
First Line	:	301 EAST ST
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-1846
Country	:	US
Telephone Number	:	570-387-8800
Fax Number	:	570-784-8887

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/08/2007

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