Provider Demographics
NPI:1487667085
Name:MANCUSO, JOHN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2721 HARWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-5525
Mailing Address - Country:US
Mailing Address - Phone:718-449-6226
Mailing Address - Fax:718-996-7531
Practice Address - Street 1:8310 RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209
Practice Address - Country:US
Practice Address - Phone:718-238-7044
Practice Address - Fax:718-833-5686
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY132333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00506643Medicaid
NY00506643Medicaid
NY33A661Medicare ID - Type Unspecified