Basic Information
| Provider Information | |||||||||
| NPI: | 1134303035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANCUSO | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4411 MEDICAL DR | ||||||||
| Address2: | 300 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106145400 | ||||||||
| FaxNumber: | 2106142413 | ||||||||
| Practice Location | |||||||||
| Address1: | 12709 TOEPPERWEIN RD STE 306 | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109670096 | ||||||||
| FaxNumber: | 2109670383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N2181 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 316704YR99 | 01 | TX | MEDICARE | OTHER | 284764203 | 05 | TX | MEDICAID | 8DV607 | 01 | TX | BCBSTX | OTHER | P01251180 | 01 | TX | RR MEDICARE | OTHER |