Provider Demographics
NPI:1568994093
Name:COSTELLO, SEAN RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:RYAN
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:7750 TEN TEN RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-8852
Practice Address - Country:US
Practice Address - Phone:919-235-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-1962207Q00000X
390200000X
NC2022-00741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1568994093Medicaid