Provider Demographics
NPI:1083901078
Name:MANCUSO, ALICIA M (DO)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:M
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:16 CONCOURSE W
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6007
Mailing Address - Country:US
Mailing Address - Phone:207-861-1036
Mailing Address - Fax:207-861-1039
Practice Address - Street 1:15 ANCHOR DR STE 201
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-3848
Practice Address - Country:US
Practice Address - Phone:207-301-5900
Practice Address - Fax:207-301-5358
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine