Provider Demographics
NPI:1396852497
Name:MANCUSO, MARTIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:M
Last Name:MANCUSO
Suffix:
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 1:7100 W CENTER RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-2700
Mailing Address - Country:US
Mailing Address - Phone:402-506-9106
Mailing Address - Fax:402-858-7104
Practice Address - Street 1:7100 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-2700
Practice Address - Country:US
Practice Address - Phone:402-506-9106
Practice Address - Fax:402-858-7104
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE828013494OtherTRAVELERS RR MEDICARE
NED92381Medicare UPIN
NE095146Medicare ID - Type Unspecified
NE47064137900Medicaid