Provider Demographics
NPI:1922268143
Name:COSTARELLI, PETER (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:COSTARELLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE # 4903
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-9800
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:702-716-5785
Practice Address - Street 1:16 WOODBINE LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-8029
Practice Address - Country:US
Practice Address - Phone:570-271-6531
Practice Address - Fax:570-271-7146
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist