Provider Demographics
NPI:1679523468
Name:LLOYD COSTELLO MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LLOYD COSTELLO MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-865-5777
Mailing Address - Street 1:1902 ROYALTY DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3030
Mailing Address - Country:US
Mailing Address - Phone:909-865-5777
Mailing Address - Fax:909-865-5781
Practice Address - Street 1:1902 ROYALTY DR
Practice Address - Street 2:SUITE 130
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3030
Practice Address - Country:US
Practice Address - Phone:909-865-5777
Practice Address - Fax:909-865-5781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN