Provider Demographics
NPI:1528349396
Name:COSTANZO, KATHLEEN A (DO)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W 24TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2666
Mailing Address - Country:US
Mailing Address - Phone:814-454-4484
Mailing Address - Fax:
Practice Address - Street 1:311 W 24TH ST STE 305
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2666
Practice Address - Country:US
Practice Address - Phone:814-454-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014849207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30106933OtherAMERIHEALTH MERCY - WMG
MD441180300Medicaid
PA417898OtherUPMC
PA1602874OtherGATEWAY
PA102645606Medicaid
PA102645606Medicaid
PA229889FLTMedicare PIN