Basic Information
| Provider Information | |||||||||
| NPI: | 1558745729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANCUSO | ||||||||
| FirstName: | ANA | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALAZAR | ||||||||
| OtherFirstName: | ANA | ||||||||
| OtherMiddleName: | V. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6511 US HIGHWAY 181 N | ||||||||
| Address2: | |||||||||
| City: | FLORESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303931400 | ||||||||
| FaxNumber: | 8303931749 | ||||||||
| Practice Location | |||||||||
| Address1: | 6511 US HIGHWAY 181 N | ||||||||
| Address2: | |||||||||
| City: | FLORESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303931400 | ||||||||
| FaxNumber: | 8303931749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2015 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R5805 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3859852-03 | 01 | TX | CSHCN | OTHER | 3859852-02 | 05 | TX | MEDICAID |