Provider Demographics
NPI:1083685994
Name:MANCINO, LAWRENCE (DO)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:MANCINO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 EDISON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:718-351-6377
Mailing Address - Fax:718-980-7341
Practice Address - Street 1:360 EDISON ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:718-351-6377
Practice Address - Fax:718-980-7341
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185177207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01600628Medicaid
NY110145269OtherRR MEDICARE
NY13H941Medicare PIN
NYF69021Medicare UPIN