Provider Demographics
NPI:1518970748
Name:CONSTANTINOU, COSTAS L (MD)
Entity Type:Individual
Prefix:
First Name:COSTAS
Middle Name:L
Last Name:CONSTANTINOU
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 1:500 JOHN DEERE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6892
Mailing Address - Country:US
Mailing Address - Phone:309-779-4944
Mailing Address - Fax:309-779-4989
Practice Address - Street 1:500 JOHN DEERE RD STE 102
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6892
Practice Address - Country:US
Practice Address - Phone:309-779-4944
Practice Address - Fax:309-779-4989
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087414207RX0202X
IA32688207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3217588Medicaid
F84667Medicare UPIN
ILK24664Medicare PIN
IAI16776Medicare PIN