Healthcare Provider Details

I. General information

NPI: 1699776955
Provider Name (Legal Business Name): JOHN ROMEO MANSUETI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11105 CATHAGE RD
BERLIN MD
21811-2131
US

IV. Provider business mailing address

PO BOX 418837
BOSTON MA
02241-8837
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-4966
  • Fax: 410-912-5967
Mailing address:
  • Phone: 607-324-2340
  • Fax: 607-324-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0101228433
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: