Provider Demographics
NPI:1982754750
Name:MANSUETO, JOSE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:L
Last Name:MANSUETO
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 1:483 EASTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2112
Mailing Address - Country:US
Mailing Address - Phone:201-652-3978
Mailing Address - Fax:
Practice Address - Street 1:1249 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4413
Practice Address - Country:US
Practice Address - Phone:212-360-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111419208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE61169Medicare UPIN