Healthcare Provider Details

I. General information

NPI: 1912977646
Provider Name (Legal Business Name): MITA GUPTA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8912 CENTREVILLE RD
MANASSAS VA
20110-8455
US

IV. Provider business mailing address

13109 OAT CT
WOODBRIDGE VA
22193-7010
US

V. Phone/Fax

Practice location:
  • Phone: 703-361-6151
  • Fax: 703-361-1750
Mailing address:
  • Phone: 804-929-6829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001643
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: