Basic Information
| Provider Information | |||||||||
| NPI: | 1699785832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COSTELLO EYE PHYSICIANS & SURGEONS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154721488 | ||||||||
| FaxNumber: | 3154721488 | ||||||||
| Practice Location | |||||||||
| Address1: | 578 SENECA ST | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134212600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153631110 | ||||||||
| FaxNumber: | 3153634441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | COSTELLO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3153631110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 02887589 | 05 | NY | MEDICAID |