Provider Demographics
NPI:1962693317
Name:MANCINI, ERICA LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:ERICA
Middle Name:LYNN
Last Name:MANCINI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ERICA
Other - Middle Name:LYNN
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3000 HAMPTON CTR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1708
Mailing Address - Country:US
Mailing Address - Phone:304-598-2020
Mailing Address - Fax:
Practice Address - Street 1:3000 HAMPTON CTR
Practice Address - Street 2:SUITE A
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1708
Practice Address - Country:US
Practice Address - Phone:304-598-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5734152W00000X
WV1052-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013688Medicaid
WV4283561OtherMEDICARE PTAN