Provider Demographics
NPI:1700843398
Name:MANCUSO, ANTHONY J (OD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:MANCUSO
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 1:155 E MARKET ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-1357
Mailing Address - Country:US
Mailing Address - Phone:724-459-6610
Mailing Address - Fax:724-459-6630
Practice Address - Street 1:155 E MARKET ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-1357
Practice Address - Country:US
Practice Address - Phone:724-459-6610
Practice Address - Fax:724-459-6630
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000818152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00346769OtherRAILROAD MEDICARE
PA631152Medicare PIN
PAP00346769OtherRAILROAD MEDICARE