Healthcare Provider Details

I. General information

NPI: 1821591355
Provider Name (Legal Business Name): CARINE MUNGO TATA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 G ST NW STE 104
WASHINGTON DC
20006-4765
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 202-298-6878
  • Fax: 202-347-7180
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP2000603
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberI3-0001410
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: