Healthcare Provider Details

I. General information

NPI: 1821679069
Provider Name (Legal Business Name): JOHN SAMUEL COSTANZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 05/03/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6431 FANNIN STREET MSB 2.262
HOUSTON TX
77030
US

IV. Provider business mailing address

14827 SILENT GULF AVE
HOUSTON TX
77082-3191
US

V. Phone/Fax

Practice location:
  • Phone: 713-500-5302
  • Fax: 713-500-0712
Mailing address:
  • Phone: 602-885-2605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: