Healthcare Provider Details

I. General information

NPI: 1497718233
Provider Name (Legal Business Name): PAUL ANTHONY MANCUSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 11/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE STE 240
ORLANDO FL
32804-4641
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 240
ORLANDO FL
32804-4641
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2615
  • Fax:
Mailing address:
  • Phone: 407-303-2615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME90970
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: