MEDICARE: DR. TARA MANGAT MD

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	2084P0800X	Psychiatry Physician	0101232595	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	146222	OTHER	VA	ANTHEM BC

General Provider Information

NPI Number	:	1649256603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA MANGAT MD

Provider Business Mailing Address
First Line	:	PO BOX 825
Second Line	:
City	:	ASHBURN
State	:	VA
Zip	:	20146-0825
Country	:	US
Telephone Number	:	703-858-0076
Fax Number	:	703-726-6394

Provider Business Practice Location Address
First Line	:	19415 DEERFIELD AVE
Second Line	:	310
City	:	LANSDOWNE
State	:	VA
Zip	:	20176-8452
Country	:	US
Telephone Number	:	703-858-0076
Fax Number	:	703-726-6394

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	02/27/2008

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