1568442275 NPI number — DR. ANDREW F MANSUETO O.D.

Table of content: DR. ANDREW F MANSUETO O.D. (NPI 1568442275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568442275 NPI number — DR. ANDREW F MANSUETO O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANSUETO
Provider First Name:
ANDREW
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1568442275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
942 RICHARD RD
Provider Second Line Business Mailing Address:
P.O. BOX 367
Provider Business Mailing Address City Name:
DYER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46311-1936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-864-1430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
942 RICHARD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DYER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46311-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-864-1430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2006

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: 152W00000X , with the licence number:  18002573 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100424350A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35-1883918 . This is a "VSP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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