Provider Demographics
NPI:1366708885
Name:MANCUSO, MICHAEL ROBERT (MD/PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DRIVE
Mailing Address - Street 2:GRANT S101
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-5109
Mailing Address - Country:US
Mailing Address - Phone:925-899-2029
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DRIVE
Practice Address - Street 2:GRANT S101
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-5109
Practice Address - Country:US
Practice Address - Phone:925-899-2029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program