Provider Demographics
NPI:1396850269
Name:ECONOMOUS, CONSTANTINE V (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANTINE
Middle Name:V
Last Name:ECONOMOUS
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 1:2370 SOUTHEAST BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3418
Mailing Address - Country:US
Mailing Address - Phone:330-332-9961
Mailing Address - Fax:
Practice Address - Street 1:2370 SOUTHEAST BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-3418
Practice Address - Country:US
Practice Address - Phone:330-332-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0377597Medicaid
OH0377597Medicaid
OHG51904Medicare UPIN