Provider Demographics
NPI:1154411254
Name:COSTELLO, GREGORY ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ANTHONY
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 1:587 EDER AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-3011
Mailing Address - Country:US
Mailing Address - Phone:201-847-2422
Mailing Address - Fax:
Practice Address - Street 1:700 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1047
Practice Address - Country:US
Practice Address - Phone:201-848-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06626300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7619804Medicaid