Provider Demographics
NPI:1427030634
Name:COSTANZO, GEORGE P (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:P
Last Name:COSTANZO
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 1:3278 MICTCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-3891
Mailing Address - Fax:
Practice Address - Street 1:347TH MEDICAL GROUP
Practice Address - Street 2:3278 MITCHELL BLVD
Practice Address - City:MOODY A F B
Practice Address - State:GA
Practice Address - Zip Code:31699-0001
Practice Address - Country:US
Practice Address - Phone:229-257-3755
Practice Address - Fax:229-257-4672
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55933208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery