Provider Demographics
NPI:1558375204
Name:COSTANZA, JANE (OD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 LIMESTONE RD STE 128
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1253
Mailing Address - Country:US
Mailing Address - Phone:302-239-1933
Mailing Address - Fax:
Practice Address - Street 1:46 HEMPSTEAD DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-7711
Practice Address - Country:US
Practice Address - Phone:302-838-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE14-0000015152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE020134S05Medicare PIN