Provider Demographics
NPI:1215340245
Name:COSTICH, MARGUERITE ANN (MD)
Entity type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:ANN
Last Name:COSTICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST # VC4-417
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:773-702-7553
Mailing Address - Fax:212-305-2229
Practice Address - Street 1:622 W 168TH ST # VC4-417
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:773-702-7553
Practice Address - Fax:212-305-2229
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287921208000000X
IL125-064443208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics