Provider Demographics
NPI:1780643759
Name:MANTHOUS, CONSTANTINE A (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANTINE
Middle Name:A
Last Name:MANTHOUS
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 1:100 GRAND ST
Mailing Address - Street 2:100 GRAND STREET
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-2016
Mailing Address - Country:US
Mailing Address - Phone:860-224-5011
Mailing Address - Fax:
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:100 GRAND STREET
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2016
Practice Address - Country:US
Practice Address - Phone:860-224-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031195207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001311951Medicaid
CT001311951Medicaid
CT110004976Medicare ID - Type Unspecified