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General NPI Number Information
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NPI Number | 1558339200
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Entity Type | Individual
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Provider Name | PETER JOHN MANCUSO DPM
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Gender | Male
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Dates
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Enumeration Date | 03/09/2006
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Last Update Date | 04/27/2017
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Provider Practice Location Address
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Address Line | 620 SUFFOLK AVE
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City | BRENTWOOD
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State | NY
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Zip | 11717-4306
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Country | US
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Telephone | 631-231-1401
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Fax | 631-273-0125
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Provider Business Mailing Address
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Address Line | 620 SUFFOLK AVE
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City | BRENTWOOD
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State | NY
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Zip | 11717-4306
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Country | US
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Telephone | 631-231-1401
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Fax | 631-273-0125
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | N0056351
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License Number State | NY
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