Provider Demographics
NPI:1962443895
Name:EBONG, CONSTANCE NZELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:NZELLE
Last Name:EBONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-2304
Mailing Address - Fax:717-851-3374
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-2304
Practice Address - Fax:717-851-3374
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0812092084P0800X
PAMD4264972084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3086299Medicaid
PA537535OtherVALUE OPTIONS
PA03261100OtherCAPITAL BLUE CROSS
PA2144099OtherMAMSI
OHP01006215OtherMEDICARE RAILROAD
PA646136-01OtherBC/BS OF MD CARE FIRST
PA793763000OtherMAGELLAN
PAP00241086OtherMEDICARE RAILROAD
PA1737478OtherPA BLUE SHIELD
PA2239500OtherCIGNA BEHAVIORAL HEALTH
PA101308236Medicaid
PA793763000OtherMAGELLAN
PA2144099OtherMAMSI
OH3086299Medicaid
PA091779G9BMedicare PIN
PA241155EZ3Medicare PIN