Provider Demographics
NPI:1174546790
Name:MANCINI, MARY CATHERINE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:MANCINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2713
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:1453 E BERT KOUNS INDUSTRIAL LOOP STE 319
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-6800
Practice Address - Country:US
Practice Address - Phone:318-681-1968
Practice Address - Fax:318-681-1969
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.08695R208600000X, 2086S0102X
LA08695R208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1914801Medicaid
LA5N618F610Medicare ID - Type Unspecified
LA1914801Medicaid
LAA17195Medicare UPIN