Provider Demographics
NPI:1063498418
Name:MANCUSO, MARC ANGELO (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANGELO
Last Name:MANCUSO
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 1:700 E MOREHEAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2742
Mailing Address - Country:US
Mailing Address - Phone:704-334-7800
Mailing Address - Fax:704-414-7512
Practice Address - Street 1:700 E MOREHEAD ST STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2742
Practice Address - Country:US
Practice Address - Phone:704-334-7800
Practice Address - Fax:704-414-7512
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007003352085P0229X, 2085R0202X
NH126262085R0202X
MA2275562085R0202X
SC298922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906571Medicaid
SCN00337Medicaid
NCP00410888OtherRR MEDICAIRE
NCP00410888OtherRR MEDICAIRE
SCN00337Medicaid