Provider Demographics
NPI:1467401802
Name:COSTANZO, GEORGE J (DC)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:J
Last Name:COSTANZO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-2529
Mailing Address - Country:US
Mailing Address - Phone:860-621-0131
Mailing Address - Fax:860-621-1533
Practice Address - Street 1:340 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-2529
Practice Address - Country:US
Practice Address - Phone:860-621-0131
Practice Address - Fax:860-621-1533
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8461363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22584Medicare UPIN