Provider Demographics
NPI:1679577647
Name:COSTLEY, ELIZABETH M (DO)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:M
Last Name:COSTLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:360 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3702
Mailing Address - Country:US
Mailing Address - Phone:845-338-7140
Mailing Address - Fax:845-338-7141
Practice Address - Street 1:360 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3702
Practice Address - Country:US
Practice Address - Phone:845-338-7140
Practice Address - Fax:845-338-7141
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208510-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02099250Medicaid
228061OtherWELLCARE
69115OtherGHI HMO
EM032V1510OtherEMPIRE BLUE CROSS
NY855858OtherMVP
NY10053448OtherCDPHP
080167991OtherRAILROAD MEDICARE
EM032V1510OtherEMPIRE BLUE CROSS
NY10053448OtherCDPHP