Provider Demographics
NPI:1215138144
Name:COSTALDI, MARIO E (MD)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:E
Last Name:COSTALDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIO
Other - Middle Name:E
Other - Last Name:COSTALDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8051 DEER TRL
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-7459
Mailing Address - Country:US
Mailing Address - Phone:476-936-1537
Mailing Address - Fax:
Practice Address - Street 1:8051 DEER TRL
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-7459
Practice Address - Country:US
Practice Address - Phone:476-936-1537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-2511208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARAC8266492OtherDEA NUMBER
ARAC8266492OtherDEA NUMBER
AR51178Medicare ID - Type Unspecified