MEDICARE: MS. ALYSSA BROOKE MANCUSO OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TUV008066	NY

General Provider Information

NPI Number	:	1992123814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALYSSA BROOKE MANCUSO OD

Provider Business Mailing Address
First Line	:	825 E GATE BLVD STE 111
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-2136
Country	:	US
Telephone Number	:	516-804-5200
Fax Number	:

Provider Business Practice Location Address
First Line	:	711 STEWART AVE
Second Line	:	STE 160
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-4731
Country	:	US
Telephone Number	:	516-500-4200
Fax Number	:	516-400-4124

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2014
Last Update Date	:	09/16/2019

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