Provider Demographics
NPI:1114970936
Name:KONSTANTELOS, CHRISTOS (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOS
Middle Name:
Last Name:KONSTANTELOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 228
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-8050
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:STE 306
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-8512
Practice Address - Fax:616-336-9952
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012211208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4774950Medicaid
MIMI3233132Medicare PIN
MI4774950Medicaid