Provider Demographics
NPI:1962497024
Name:MANCUSO, SCOTT ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANTHONY
Last Name:MANCUSO
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 1:1146 CORONA LN
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5525
Mailing Address - Country:US
Mailing Address - Phone:602-317-7744
Mailing Address - Fax:
Practice Address - Street 1:7755 CENTER AVE STE 630
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-9152
Practice Address - Country:US
Practice Address - Phone:657-400-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ874132-01Medicaid
AZ874132-01Medicaid
AZZ80664Medicare PIN