Provider Demographics
NPI:1114935756
Name:MANCUSO, DAWN B (MD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:B
Last Name:MANCUSO
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:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-0617
Mailing Address - Country:US
Mailing Address - Phone:256-325-4365
Mailing Address - Fax:256-461-0393
Practice Address - Street 1:12205 COUNTY LINE RD
Practice Address - Street 2:SUITE B
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-7719
Practice Address - Country:US
Practice Address - Phone:256-325-4365
Practice Address - Fax:256-461-0393
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051506404OtherBC/BS
ALE91320Medicare UPIN
AL051551297Medicare ID - Type Unspecified