Provider Demographics
NPI:1396743290
Name:MANTZ, CONSTANTINE A (MD)
Entity type:Individual
Prefix:
First Name:CONSTANTINE
Middle Name:A
Last Name:MANTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GUS
Other - Middle Name:A
Other - Last Name:MANTZAVRAKOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1419 SE 8TH TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3213
Practice Address - Country:US
Practice Address - Phone:239-772-3202
Practice Address - Fax:239-773-8346
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME808382085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00794OtherUNIV. HLTHCR. PROVIDER #
FL160065OtherWELLCARE (STAYWELL-MEDICAID AND WELLCARE-MEDICARE)
FL4968199-001OtherCIGNA PROVIDER NUMBER
FLME80838AOtherMETCARE PROVIDER ID #
FL8329OtherAVMED PIN NUMBER
FL207227OtherAMERIGROUP GROUP #
FL592485899OtherMETCARE VENDOR ID #
FL7082137OtherAETNA PROVIDER NUMBER
FL24-00187OtherUTD. HLTHCR. PROVIDER #
FL259822100Medicaid
FL85447OtherOP. ENG. LOC. 825 PROV. #
FL272205OtherAVMED PROVIDER NUMBER
FL259822100Medicaid
FL35723YMedicare PIN