Basic Information
| Provider Information | |||||||||
| NPI: | 1255397667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANCUSO | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | SMITH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 MEADE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234344259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390251 | ||||||||
| FaxNumber: | 7579239610 | ||||||||
| Practice Location | |||||||||
| Address1: | 4868 BRIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234352048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574837900 | ||||||||
| FaxNumber: | 7574837151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
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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 | 208000000X | 0101018464 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6711987 | 05 | VA | MEDICAID |