Provider Demographics
NPI:1053764936
Name:DICOSTANZO, MICHELLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:DICOSTANZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:7890 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-2468
Practice Address - Country:US
Practice Address - Phone:219-947-7880
Practice Address - Fax:219-962-9772
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-10580207Q00000X
IN01082458A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine