Provider Demographics
NPI:1104882208
Name:ANTHONY J. MANCUSO, OD, LLC
Entity type:Organization
Organization Name:ANTHONY J. MANCUSO, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-459-6610
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000818152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADF2054OtherRAILROAD MEDICARE
PA104188Medicare PIN
PA5842470001Medicare NSC