MEDICARE: JOHN J COSTELLO JR. DO

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	207W00000X	Ophthalmology Physician	194090	NY

General Provider Information

NPI Number	:	1487650743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN J COSTELLO JR. DO

Provider Business Mailing Address
First Line	:	131 MAIN ST
Second Line	:	SUITE 201
City	:	ONEIDA
State	:	NY
Zip	:	13421-1641
Country	:	US
Telephone Number	:	315-367-0264
Fax Number	:	315-693-0014

Provider Business Practice Location Address
First Line	:	131 MAIN ST
Second Line	:	SUITE 201
City	:	ONEIDA
State	:	NY
Zip	:	13421-1641
Country	:	US
Telephone Number	:	315-367-0264
Fax Number	:	315-693-0014

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	01/02/2015

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