Provider Demographics
NPI:1568456275
Name:MANCINI, THOMAS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:MANCINI
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 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:571-291-6131
Mailing Address - Fax:571-291-6135
Practice Address - Street 1:21170 ASHBY PONDS BLVD
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6128
Practice Address - Country:US
Practice Address - Phone:571-291-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044028207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010131308Medicaid
VAP00199970OtherRR MEDICARE
E07635Medicare UPIN
VA010131308Medicaid
DC016617L26Medicare PIN