Provider Demographics
NPI:1558368035
Name:MICHELL, CONSTANTINE W (DO)
Entity Type:Individual
Prefix:
First Name:CONSTANTINE
Middle Name:W
Last Name:MICHELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-1818
Mailing Address - Country:US
Mailing Address - Phone:302-738-5500
Mailing Address - Fax:302-738-9449
Practice Address - Street 1:89 OMEGA DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2065
Practice Address - Country:US
Practice Address - Phone:302-738-5500
Practice Address - Fax:302-738-9449
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0000333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000132803Medicaid
DEC48564Medicare UPIN
DE0000132803Medicaid