Provider Demographics
NPI:1538247549
Name:COSTABILE, THOMAS ANTHONY (OD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ANTHONY
Last Name:COSTABILE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-7415
Mailing Address - Country:US
Mailing Address - Phone:919-969-9644
Mailing Address - Fax:919-969-9774
Practice Address - Street 1:1816 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-7415
Practice Address - Country:US
Practice Address - Phone:919-969-9644
Practice Address - Fax:919-969-9774
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909188Medicaid
2473846Medicare ID - Type Unspecified
NC8909188Medicaid