Provider Demographics
NPI:1104874791
Name:COSTAS, ANGELO ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:ANDREW
Last Name:COSTAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 S MICHIGAN AVE
Mailing Address - Street 2:SUITE 805
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-2402
Mailing Address - Country:US
Mailing Address - Phone:312-922-3815
Mailing Address - Fax:312-922-3789
Practice Address - Street 1:200 S MICHIGAN AVE
Practice Address - Street 2:SUITE 805
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-2402
Practice Address - Country:US
Practice Address - Phone:312-922-3815
Practice Address - Fax:312-922-3789
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360927291Medicaid
IL036092729OtherILL LIC #
IL036092729OtherILL LIC #
ILL59235Medicare PIN