Healthcare Provider Details

I. General information

NPI: 1487888673
Provider Name (Legal Business Name): MARC WILLIAM MANSEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 W 18TH ST
NEW YORK NY
10011-4401
US

IV. Provider business mailing address

237 DEVOE ST APT 3R
BROOKLYN NY
11211-3806
US

V. Phone/Fax

Practice location:
  • Phone: 347-687-4704
  • Fax:
Mailing address:
  • Phone: 401-524-1545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number258596
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number258596
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: