Organization
DIANA M MANCUSO MD PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DIANA M MANCUSO M.D. (PRESIDENT)
(334) 793-4120
Entity
Organization
Contact information
Practice address
4300 W MAIN ST, SUITE 16, DOTHAN, AL 36305-1054
(334) 793-4120
(334) 615-8443
Mailing address
4300 W MAIN ST, SUITE 16, DOTHAN, AL 36305-1054
(334) 793-4120
(334) 615-8443
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
4436
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000013
MEDICARE PROVIDER NUMBER
AL
05
—
000000013
—
AL
Enumeration date
09/26/2008
Last updated
03/09/2009
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