Provider Demographics
NPI:1366584724
Name:DIAKOLIOS, CONSTANTINE (MD)
Entity type:Individual
Prefix:
First Name:CONSTANTINE
Middle Name:
Last Name:DIAKOLIOS
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 1:404 DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-1412
Mailing Address - Country:US
Mailing Address - Phone:201-363-9354
Mailing Address - Fax:201-363-9352
Practice Address - Street 1:1776 CLAY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7239
Practice Address - Country:US
Practice Address - Phone:718-299-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ199836-1207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G39669Medicare UPIN
16N421Medicare ID - Type Unspecified