Provider Demographics
NPI:1972561322
Name:MANCANO, LOUIS (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:MANCANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:484-628-0799
Mailing Address - Fax:
Practice Address - Street 1:301 S 7TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1410
Practice Address - Country:US
Practice Address - Phone:610-988-8198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034586E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001130734Medicaid
PA001130734Medicaid