Provider Demographics
NPI:1770582504
Name:SOLACOFF, KONSTANTINE K (MD)
Entity type:Individual
Prefix:DR
First Name:KONSTANTINE
Middle Name:K
Last Name:SOLACOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1075
Mailing Address - Country:US
Mailing Address - Phone:419-294-2375
Mailing Address - Fax:419-294-2412
Practice Address - Street 1:777 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1075
Practice Address - Country:US
Practice Address - Phone:419-294-2375
Practice Address - Fax:419-294-2412
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-021270208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH8269332Medicaid
OHS00109801Medicare ID - Type Unspecified
C00349Medicare UPIN