Provider Demographics
NPI:1548011240
Name:MANCUSO, DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7859 SKIING WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-6208
Mailing Address - Country:US
Mailing Address - Phone:407-506-4818
Mailing Address - Fax:
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5054
Practice Address - Country:US
Practice Address - Phone:850-431-7900
Practice Address - Fax:850-431-7990
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2025-04-23
Deactivation Date:2024-03-29
Deactivation Code:
Reactivation Date:2024-04-13
Provider Licenses
StateLicense IDTaxonomies
FLM522-163-98-150-0207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine