Provider Demographics
NPI:1164522124
Name:MIGNOGNA, MATTHEW PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PAUL
Last Name:MIGNOGNA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:706 GRAPE ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-5207
Practice Address - Country:US
Practice Address - Phone:610-266-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE-007828-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist