Healthcare Provider Details

I. General information

NPI: 1528023439
Provider Name (Legal Business Name): ROBERT F MANCUSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E CAMBRIDGE AVE STE 201
PHOENIX AZ
85006-1462
US

IV. Provider business mailing address

2108 E THOMAS RD
PHOENIX AZ
85016-7761
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-3277
  • Fax: 602-933-4326
Mailing address:
  • Phone: 602-933-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number28884
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number28884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: