Healthcare Provider Details

I. General information

NPI: 1649433210
Provider Name (Legal Business Name): MATTHEW WAYNE CONSTANTINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STONY BROOK UNIVERSITY HOSP HSC, LEVEL 4, ROOM 080
STONY BROOK NY
11794-8350
US

IV. Provider business mailing address

STONY BROOK UNIVERSITY HOSP HSC, LEVEL 4, ROOM 080
STONY BROOK NY
11794-8350
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2478
  • Fax:
Mailing address:
  • Phone: 631-444-2478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number251045
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberP365
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: