Provider Demographics
NPI:1992722748
Name:COSTANTINO, ALICIA (MD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:COSTANTINO
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:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:2055 W HOSPITAL DR
Practice Address - Street 2:STE 115
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7892
Practice Address - Country:US
Practice Address - Phone:520-797-0011
Practice Address - Fax:520-797-7550
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24289207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ349987Medicaid
AZZ73778Medicare PIN