Healthcare Provider Details

I. General information

NPI: 1649912692
Provider Name (Legal Business Name): MICHAEL S. MANCANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14290 METROPOLIS AVE STE 1
FORT MYERS FL
33912-4534
US

IV. Provider business mailing address

14290 METROPOLIS AVE STE 1
FORT MYERS FL
33912-4534
US

V. Phone/Fax

Practice location:
  • Phone: 239-275-1114
  • Fax: 239-275-0498
Mailing address:
  • Phone: 239-275-1114
  • Fax: 239-275-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016006040
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO4637
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: