Provider Demographics
NPI:1538401732
Name:COSTANZA, NICHOLAS SALVATORE (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:SALVATORE
Last Name:COSTANZA
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:4225 FROST GRASS DR
Mailing Address - Street 2:HENRY FORD MACOMB HOSPITALS
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8010
Mailing Address - Country:US
Mailing Address - Phone:248-404-0471
Mailing Address - Fax:
Practice Address - Street 1:4225 FROST GRASS DR
Practice Address - Street 2:HENRY FORD MACOMB HOSPITALS
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8010
Practice Address - Country:US
Practice Address - Phone:248-404-0471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02004817A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine