MEDICARE: DR. JOSE L MANSUETO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	111419	NY

General Provider Information

NPI Number	:	1982754750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSE L MANSUETO M.D.

Provider Business Mailing Address
First Line	:	483 EASTBROOK RD
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-2112
Country	:	US
Telephone Number	:	201-652-3978
Fax Number	:

Provider Business Practice Location Address
First Line	:	1249 5TH AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10029-4413
Country	:	US
Telephone Number	:	212-360-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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