Provider Demographics
NPI:1376712232
Name:ANDREW F. MANSUETO, O.D.
Entity Type:Organization
Organization Name:ANDREW F. MANSUETO, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:F
Authorized Official - Last Name:MANSUETO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-864-1430
Mailing Address - Street 1:942 RICHARD RD
Mailing Address - Street 2:P.O. BOX 367
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1936
Mailing Address - Country:US
Mailing Address - Phone:219-864-1430
Mailing Address - Fax:219-864-1780
Practice Address - Street 1:942 RICHARD RD
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1936
Practice Address - Country:US
Practice Address - Phone:219-864-1430
Practice Address - Fax:219-864-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002573332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0706240001Medicare NSC