Provider Demographics
NPI:1164657342
Name:MANGUIKIAN, ALEX DERTAD (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:DERTAD
Last Name:MANGUIKIAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9936 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3901
Mailing Address - Country:US
Mailing Address - Phone:703-591-4884
Mailing Address - Fax:
Practice Address - Street 1:9936 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3901
Practice Address - Country:US
Practice Address - Phone:703-591-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253390207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology