Provider Demographics
NPI:1821591355
Name:TATA, CARINE MUNGO (OD)
Entity Type:Individual
Prefix:DR
First Name:CARINE
Middle Name:MUNGO
Last Name:TATA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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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:866-795-4020
Practice Address - Street 1:1237 QUINTILIO DR
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-6005
Practice Address - Country:US
Practice Address - Phone:302-838-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001410152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist