Provider Demographics
NPI:1073734828
Name:MANCINI, JOHN (MSPT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MANCINI
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 COMMACK RD
Mailing Address - Street 2:STE B
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5515
Mailing Address - Country:US
Mailing Address - Phone:631-522-1955
Mailing Address - Fax:
Practice Address - Street 1:375 COMMACK RD
Practice Address - Street 2:STE B
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5515
Practice Address - Country:US
Practice Address - Phone:631-522-1955
Practice Address - Fax:631-522-1957
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP2231Medicare ID - Type Unspecified