Basic Information
| Provider Information | |||||||||
| NPI: | 1326009986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANCINI | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 STONE RD | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032662442 | ||||||||
| FaxNumber: | 7032667158 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 STONE RD | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032662442 | ||||||||
| FaxNumber: | 7032667158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
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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 | 207Q00000X | 0101054998 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010018587 | 05 | VA | MEDICAID |