Provider Demographics
NPI:1124550496
Name:COSTELLO, JUSTIN ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALEXANDER
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT OF INTERNAL MEDICINE U OF UTAH MEDICINE
Mailing Address - Street 2:30 NORTH 1900 EAST, ROOM 4C104
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-501-7606
Mailing Address - Fax:
Practice Address - Street 1:513 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-0381
Practice Address - Country:US
Practice Address - Phone:828-436-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10957022-12052085R0202X
NC2022-033412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology