Provider Demographics
NPI:1992123814
Name:MANCUSO, ALYSSA BROOKE (OD)
Entity type:Individual
Prefix:MS
First Name:ALYSSA
Middle Name:BROOKE
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E GATE BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2136
Mailing Address - Country:US
Mailing Address - Phone:516-804-5200
Mailing Address - Fax:
Practice Address - Street 1:711 STEWART AVE
Practice Address - Street 2:STE 160
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4731
Practice Address - Country:US
Practice Address - Phone:516-500-4200
Practice Address - Fax:516-400-4124
Is Sole Proprietor?:No
Enumeration Date:2014-03-29
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008066152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400101718Medicare PIN