Provider Demographics
NPI:1568442275
Name:MANSUETO, ANDREW F (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:F
Last Name:MANSUETO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100424350AMedicaid
IN35-1883918OtherVSP
410034545Medicare PIN
IN35-1883918OtherVSP
IN405140Medicare PIN