Provider Demographics
NPI:1144398546
Name:COSTANZO, CHRISTINE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MARIE
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703
Mailing Address - Country:US
Mailing Address - Phone:608-257-1724
Mailing Address - Fax:
Practice Address - Street 1:408 S BALDWIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-4805
Practice Address - Country:US
Practice Address - Phone:608-257-1724
Practice Address - Fax:608-257-2371
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36169-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32125800Medicaid
WI32125800Medicaid