Provider Demographics
NPI:1598759011
Name:CONSTANTINO, JORGE LUCAS P (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUCAS P
Last Name:CONSTANTINO
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 1:7 SOUTHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211-2526
Mailing Address - Country:US
Mailing Address - Phone:518-292-6000
Mailing Address - Fax:518-292-6050
Practice Address - Street 1:2231 BURDETT AVE
Practice Address - Street 2:STE 160
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2447
Practice Address - Country:US
Practice Address - Phone:518-292-6200
Practice Address - Fax:518-292-6228
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176852207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2011794Medicaid
NY01132723Medicaid
NY060067417OtherRR MEDICARE
VT1007540Medicaid
NY060067417OtherRR MEDICARE
NY01132723Medicaid
NYJ400091765Medicare PIN
NYCC8762Medicare PIN