Provider Demographics
NPI:1629091251
Name:MANCINI, ANTONIO (DO)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:MANCINI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 SOUTHWEST HWY
Mailing Address - Street 2:LL
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-1367
Mailing Address - Country:US
Mailing Address - Phone:708-581-7308
Mailing Address - Fax:708-274-4027
Practice Address - Street 1:15234 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4330
Practice Address - Country:US
Practice Address - Phone:708-633-4544
Practice Address - Fax:708-614-0607
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115425208800000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-115425Medicaid
IL036-115425OtherMEDICAL LICENSE
IL3265OtherGROUP PTAN
P00401392OtherMEDICARE RAILROAD
IL3265OtherGROUP PTAN
K37823Medicare PIN
IL036-115425OtherMEDICAL LICENSE
P00401392OtherMEDICARE RAILROAD