Provider Demographics
NPI:1245382050
Name:MANCUSI-UNGARO, HAROLD R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:R
Last Name:MANCUSI-UNGARO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:3333 MENDOCINO AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2261
Practice Address - Country:US
Practice Address - Phone:707-566-5288
Practice Address - Fax:707-566-5471
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32831208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G328310Medicaid
CA00G328310Medicaid
00G328310Medicare ID - Type Unspecified