Provider Demographics
NPI:1376531517
Name:COSTANZO, WILLIAM EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDWARD
Last Name:COSTANZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:104 PHEASANT RUN
Mailing Address - Street 2:SUITE 128
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-3439
Mailing Address - Country:US
Mailing Address - Phone:215-860-3344
Mailing Address - Fax:215-860-8950
Practice Address - Street 1:3140 PRINCETON PIKE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2306
Practice Address - Country:US
Practice Address - Phone:609-895-1919
Practice Address - Fax:609-895-1200
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD053712L207RC0000X
NJ25MA05562600207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7485409Medicaid
NJ7485409Medicaid
PA22-3505477OtherTIN
NJ46-2009036OtherTIN
PA23-2571699OtherTIN
PA22-3505477OtherTIN
NJ401614DSJMedicare ID - Type Unspecified