Provider Demographics
NPI:1699785832
Name:COSTELLO EYE PHYSICIANS & SURGEONS, PLLC
Entity type:Organization
Organization Name:COSTELLO EYE PHYSICIANS & SURGEONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:315-363-1110
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-1488
Practice Address - Street 1:578 SENECA ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2600
Practice Address - Country:US
Practice Address - Phone:315-363-1110
Practice Address - Fax:315-363-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02887589Medicaid
NYBA0926Medicare PIN
NYDF2677Medicare PIN
NYBA0925Medicare PIN