Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0100X | Gastroenterologist | 198554 | NY |
NPI | 1043251184 |
---|---|
Provider Name | Dr. John Michael Costable JR. |
First Address | Great Neck, NY 11021-5200 |
Second Address | Great Neck, NY 11021-5200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G76623 | (02) | NY |