Provider Demographics
NPI:1194955104
Name:COSTELLIC, CORINNE DIANNE (DO)
Entity type:Individual
Prefix:DR
First Name:CORINNE
Middle Name:DIANNE
Last Name:COSTELLIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD SUITE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1860
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:44199 DEQUINDRE RD STE 612
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-964-5170
Practice Address - Fax:248-964-5175
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH00799642086X0206X
MI5101018177208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD431971YGCZMedicare PIN