Provider Demographics
NPI:1215235916
Name:COSTELLO, JUSTIN (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3851 ROGER BROOKE DRIVE, FORT SAM HOUSTON
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-6200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DRIVE, FORT SAM HOUSTON
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-6200
Practice Address - Country:US
Practice Address - Phone:210-916-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE9732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology