Provider Demographics
NPI:1972768109
Name:JOHN S. MANCOLL, MD, PLLC
Entity type:Organization
Organization Name:JOHN S. MANCOLL, MD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MANCOLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-305-9185
Mailing Address - Street 1:2017 FISHER ARCH
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456
Mailing Address - Country:US
Mailing Address - Phone:757-305-9185
Mailing Address - Fax:757-305-9186
Practice Address - Street 1:1925 GLENN MITCHELL DR STE 206
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-0170
Practice Address - Country:US
Practice Address - Phone:757-305-9185
Practice Address - Fax:757-305-9186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9571211OtherAETNA
VAGC1084Medicare PIN