Provider Demographics
NPI:1689850489
Name:CONSTANTINE, GINA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:MARIE
Last Name:CONSTANTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:CONSTANTINE PORTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1845 PRECINCT LINE RD
Mailing Address - Street 2:STE 209
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3109
Mailing Address - Country:US
Mailing Address - Phone:817-336-4638
Mailing Address - Fax:817-336-7637
Practice Address - Street 1:1845 PRECINCT LINE RD
Practice Address - Street 2:STE 209
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3109
Practice Address - Country:US
Practice Address - Phone:817-336-4638
Practice Address - Fax:817-336-7637
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5990193400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No193400000XGroupSingle Specialty