Provider Demographics
NPI:1417971037
Name:MANCUSO, DIANA M (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 16
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-4120
Mailing Address - Fax:334-615-8443
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 16
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-4120
Practice Address - Fax:334-615-8443
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000000013Medicaid
ALC72543Medicare UPIN
AL000000013Medicare ID - Type Unspecified