Provider Demographics
NPI:1932101144
Name:COSTLEIGH, BRIAN J (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:COSTLEIGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:989 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2422
Mailing Address - Country:US
Mailing Address - Phone:302-381-2381
Mailing Address - Fax:321-724-0455
Practice Address - Street 1:1344 S APOLLO BLVD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3183
Practice Address - Country:US
Practice Address - Phone:321-441-8915
Practice Address - Fax:321-294-4107
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00045632085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00293179OtherRRMEDICARE
DE0000675901Medicaid
P00293179OtherRRMEDICARE
DEG10192Medicare UPIN