Provider Demographics
NPI:1962608620
Name:MANCUSO, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WALTER AVE APT B41
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 KINGS HWY E FL 4
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4823
Practice Address - Country:US
Practice Address - Phone:203-337-2677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5830OtherLICENSE#