Provider Demographics
NPI:1225164833
Name:PAUL A MANCUSO MD PA
Entity Type:Organization
Organization Name:PAUL A MANCUSO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-896-1100
Mailing Address - Street 1:615 E PRINCETON ST STE 510
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1424
Mailing Address - Country:US
Mailing Address - Phone:407-896-1100
Mailing Address - Fax:407-897-3700
Practice Address - Street 1:615 E PRINCETON ST
Practice Address - Street 2:STE 510
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1456
Practice Address - Country:US
Practice Address - Phone:407-896-1100
Practice Address - Fax:407-897-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90970173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE7966 RAILROADMedicare PIN
FLK6493Medicare ID - Type Unspecified