Basic Information
| Provider Information | |||||||||
| NPI: | 1598184830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTAIN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | GRANT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100237 | ||||||||
| Address2: | 1600 SW ARCHER RD., SUITE N1-07 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522735143 | ||||||||
| FaxNumber: | 3522735213 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | SUITE N1-07 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522735143 | ||||||||
| FaxNumber: | 3522735213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 4301110985 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.