Provider Demographics
NPI:1083708309
Name:CONSTANTINO, EDWIN M (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:M
Last Name:CONSTANTINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HURON AVE SUITE 1-L
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-3641
Mailing Address - Country:US
Mailing Address - Phone:201-656-0440
Mailing Address - Fax:201-656-3444
Practice Address - Street 1:10 HURON AVE APT 1L
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-3627
Practice Address - Country:US
Practice Address - Phone:201-656-0440
Practice Address - Fax:201-656-3444
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05482600208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1661400Medicaid
NJ1661400Medicaid
NJ615679SJPMedicare PIN