Provider Demographics
NPI:1235245507
Name:DJEDJOS, CONSTANTINE STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANTINE
Middle Name:STEPHEN
Last Name:DJEDJOS
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 1:1919 EAST THOMAS RD MAIN BUILDING, 2ND FLOOR
Mailing Address - Street 2:PHOENIX CHILDRENS HOSPITAL
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016
Mailing Address - Country:US
Mailing Address - Phone:602-933-0935
Mailing Address - Fax:
Practice Address - Street 1:1919 EAST THOMAS RD MAIN BUILDING, 2ND FLOOR
Practice Address - Street 2:PHOENIX CHILDRENS HOSPITAL
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-933-0935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026107207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAI24983Medicare UPIN