Healthcare Provider Details

I. General information

NPI: 1619408218
Provider Name (Legal Business Name): ELIANA COSTANTINO BURGAZZI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIANA COSTANTINO M.D.

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73D WINTHROP AVE
LAWRENCE MA
01843-3716
US

IV. Provider business mailing address

73D WINTHROP AVE
LAWRENCE MA
01843-3716
US

V. Phone/Fax

Practice location:
  • Phone: 978-686-3017
  • Fax: 978-685-4280
Mailing address:
  • Phone: 978-686-3017
  • Fax: 978-685-4280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10059763
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number292816
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: