Provider Demographics
NPI:1134303035
Name:MANCUSO, JAMES J (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:J
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4411 MEDICAL DR
Mailing Address - Street 2:300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3822
Mailing Address - Country:US
Mailing Address - Phone:210-614-5400
Mailing Address - Fax:210-614-2413
Practice Address - Street 1:12709 TOEPPERWEIN RD STE 306
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3223
Practice Address - Country:US
Practice Address - Phone:210-967-0096
Practice Address - Fax:210-967-0383
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2181207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX316704YR99OtherMEDICARE
TX284764203Medicaid
TX8DV607OtherBCBSTX
TXP01251180OtherRR MEDICARE
TXTXB136043Medicare PIN
TX316704YR99Medicare PIN