Healthcare Provider Details

I. General information

NPI: 1386604130
Provider Name (Legal Business Name): JAMES DOMINIC MANCUSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE
BETHESDA MD
20889-0004
US

IV. Provider business mailing address

8901 WISCONSIN AVE
BETHESDA MD
20889-0004
US

V. Phone/Fax

Practice location:
  • Phone: 301-648-9206
  • Fax:
Mailing address:
  • Phone: 301-648-9206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberD0068812
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: