Provider Demographics
NPI:1124380860
Name:COSTANZO, MICHELE
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10074 STATION RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA STATION
Mailing Address - State:OH
Mailing Address - Zip Code:44028-9594
Mailing Address - Country:US
Mailing Address - Phone:440-236-3937
Mailing Address - Fax:
Practice Address - Street 1:10074 STATION RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA STATION
Practice Address - State:OH
Practice Address - Zip Code:44028-9594
Practice Address - Country:US
Practice Address - Phone:440-236-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4133-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician