Provider Demographics
NPI:1821679069
Name:COSTANZA, JOHN SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SAMUEL
Last Name:COSTANZA
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 1:1331 W KING PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-3103
Mailing Address - Country:US
Mailing Address - Phone:602-885-2605
Mailing Address - Fax:
Practice Address - Street 1:1 BAYLOR PLZ
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3498
Practice Address - Country:US
Practice Address - Phone:713-798-5928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program