Provider Demographics
NPI:1710926399
Name:COSTANTINO, THOMAS G (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:COSTANTINO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1863
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:14319 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2506
Practice Address - Country:US
Practice Address - Phone:734-285-0677
Practice Address - Fax:734-285-3574
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101006373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
791126254OtherMEDICARE RAILROAD
C3241OtherM-CARE
E26804OtherHEALTH ALLIANCE PLAN
125036OtherCARE CHOICES
MI111059129Medicaid
MI5823153OtherBLUE CROSS
E26804Medicare UPIN
MI5823153OtherBLUE CROSS