Provider Demographics
NPI:1316967284
Name:WILSON-COSTELLO, DEANNE E (MD)
Entity type:Individual
Prefix:
First Name:DEANNE
Middle Name:E
Last Name:WILSON-COSTELLO
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 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6299
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-067001207L00000X, 2080N0001X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000027353OtherANTHEM
OH000000526173OtherANTHEM
OH000000221190OtherUINISON
PA0019347280001Medicaid
OH745987OtherBUCKEYE
OH0187444OtherBCMH
OH0658025OtherAETNA
OH364141OtherWELLCARE
OH0187444Medicaid
PA1019347280001OtherPENNSLYVANIA MEDICAID
OH0658025OtherAETNA
OH0187444Medicaid