Provider Demographics
NPI:1538178504
Name:COSTELLO, LAURA A (MD)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:A
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203
Mailing Address - Country:US
Mailing Address - Phone:518-489-7439
Mailing Address - Fax:518-489-1768
Practice Address - Street 1:6 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203
Practice Address - Country:US
Practice Address - Phone:518-489-7439
Practice Address - Fax:518-489-1768
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197133207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10002500Medicaid
NY10002500Medicaid
NYCC5414Medicare ID - Type Unspecified