Provider Demographics
NPI:1417914763
Name:CONSTANTINO, RICHARD S (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:S
Last Name:CONSTANTINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1445 PORTLAND AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-544-0830
Mailing Address - Fax:585-922-3609
Practice Address - Street 1:1445 PORTLAND AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-544-0830
Practice Address - Fax:585-922-3609
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00580465Medicaid
NY17425BMedicare ID - Type Unspecified
NY00580465Medicaid