Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | MB02575800 | NJ |
Y | 207Q00000X | Family Doctor | MB02575800 | NJ |
NPI | 1811978414 |
---|---|
Provider Name | John G Costino |
First Address | North Wildwood, NJ 08260-5865 |
Second Address | North Wildwood, NJ 08260-5865 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2005 |
Last Update Date | 18/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2808501 | (05) | NJ |
C52560 | (02) | NJ |