Provider Demographics
NPI:1649280215
Name:TJAHJANA, MINGLIARTI (MD)
Entity type:Individual
Prefix:DR
First Name:MINGLIARTI
Middle Name:
Last Name:TJAHJANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12504 ALEXANDER CORNELL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2437
Mailing Address - Country:US
Mailing Address - Phone:571-338-9054
Mailing Address - Fax:571-482-6080
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:SUITE 410
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:571-572-9198
Practice Address - Fax:571-482-6080
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10244579Medicaid