1134303035 NPI number — DR. JAMES J. MANCUSO MD

Table of content: HOLLY MATTHEWS (NPI 1619721958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134303035 NPI number — DR. JAMES J. MANCUSO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANCUSO
Provider First Name:
JAMES
Provider Middle Name:
J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134303035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4411 MEDICAL DR
Provider Second Line Business Mailing Address:
300
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-614-5400
Provider Business Mailing Address Fax Number:
210-614-2413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12709 TOEPPERWEIN RD STE 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVE OAK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78233-3223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-967-0096
Provider Business Practice Location Address Fax Number:
210-967-0383
Provider Enumeration Date:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  N2181 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 316704YR99 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 284764203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8DV607 . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01251180 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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