Provider Demographics
NPI:1407951171
Name:COSTANTINO, MARY MARCELLE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARCELLE
Last Name:COSTANTINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PIERZNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6958 SW VARNS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-0000
Mailing Address - Country:US
Mailing Address - Phone:503-683-7730
Mailing Address - Fax:503-914-0927
Practice Address - Street 1:6958 SW VARNS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-0000
Practice Address - Country:US
Practice Address - Phone:503-683-7730
Practice Address - Fax:503-914-0927
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD264292085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240141Medicaid
I69063Medicare UPIN
ORR158532Medicare PIN