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: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1237 QUINTILIO DR
BEAR DE
19701-6005
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 302-838-0800
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax: 866-795-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberI3-0001410
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: