Provider Demographics
NPI:1558339200
Name:MANCUSO, PETER JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:J
Other - Last Name:MANCUSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:620 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4306
Mailing Address - Country:US
Mailing Address - Phone:631-231-1401
Mailing Address - Fax:631-273-0125
Practice Address - Street 1:620 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4306
Practice Address - Country:US
Practice Address - Phone:631-231-1401
Practice Address - Fax:631-273-0125
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0056351213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02049347Medicaid
NYU72924Medicare UPIN
NYPDWH41Medicare PIN
NY02049347Medicaid