Provider Demographics
NPI:1649912692
Name:MANCANO, MICHAEL S
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:MANCANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14290 METROPOLIS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4534
Mailing Address - Country:US
Mailing Address - Phone:239-275-1114
Mailing Address - Fax:239-275-0498
Practice Address - Street 1:14290 METROPOLIS AVE STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4534
Practice Address - Country:US
Practice Address - Phone:239-275-1114
Practice Address - Fax:239-275-0498
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016006040213E00000X
FLPO4637213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist