Provider Demographics
NPI:1417272014
Name:EBRO-PROKESH, CONSTANTA T (DO)
Entity Type:Individual
Prefix:
First Name:CONSTANTA
Middle Name:T
Last Name:EBRO-PROKESH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1137 W PENN AVE
Practice Address - Street 2:
Practice Address - City:WOMELSDORF
Practice Address - State:PA
Practice Address - Zip Code:19567-9770
Practice Address - Country:US
Practice Address - Phone:610-589-2555
Practice Address - Fax:610-589-4940
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOSO14851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine