MEDICARE: ALEX DERTAD MANGUIKIAN M.D., PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	0101253390	VA

General Provider Information

NPI Number	:	1164657342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEX DERTAD MANGUIKIAN M.D., PH.D.

Provider Business Mailing Address
First Line	:	9936 MAIN ST
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-3901
Country	:	US
Telephone Number	:	703-591-4884
Fax Number	:

Provider Business Practice Location Address
First Line	:	9936 MAIN ST
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-3901
Country	:	US
Telephone Number	:	703-591-4884
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2009
Last Update Date	:	03/19/2013

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